(CAM) in a Nationwide Cohort of Women

J Relig Health DOI 10.1007/s10943-012-9569-x ORIGINAL PAPER

In God and CAM We Trust. Religious Faith and Use of Complementary and Alternative Medicine (CAM) in a Nationwide Cohort of Women Treated for Early Breast Cancer Christina Gundgaard Pedersen • Søren Christensen Anders Bonde Jensen • Robert Zachariae

•

Ó Springer Science+Business Media, LLC 2012

Abstract Turning to faith in God or a higher spiritual power is a common way of coping with life-threatening disease such as cancer. Little, however, is known about religious faith among cancer patients in secular societies. The present study aimed at exploring the prevalence of religious faith among Danish breast cancer patients and at identifying whether socio-demographic, pre-cancer health status, clinical, and health behavior characteristics, including their use of complementary and alternative medicine (CAM), were associated with their degree of faith. Information on faith in God or a higher spiritual power and use of CAM was provided by a nationwide sample of 3,128 recurrence-free Danish women who had received surgery for early-stage breast cancer 15–16 months earlier. Socio-demographic, clinical, and health status variables were obtained from national longitudinal registries, and health behaviors had been assessed at 3–4 months post-surgery. Of the women, 47.3% reported a high degree of faith (unambiguous believers), 35.9% some degree of faith (ambiguous believers), while the remaining 16.8% were non-believers. Unambiguous believers were more likely than ambiguous believers to experience their faith as having a positive impact on their disease and their disease-related quality-of-life. When compared to non-believers, unambiguous believers were also older, had poorer physical function, and were more frequent users of CAM, and more inclined to believe that their use of CAM would have a beneficial influence on their cancer. Diseaseand treatment-related variables were unrelated to faith. While overall religious faith appears equally prevalent among Danish and US breast cancer patients, the majority of Danish breast cancer patients experienced ambiguous faith, whereas the majority of US patients have been found to express unambiguous faith. Our results suggest that future studies may benefit from exploring the role of faith for health behaviors, adherence to conventional treatment, and impact upon quality of life. C. G. Pedersen (&) S. Christensen R. Zachariae Unit for Psychooncology and Health Psychology, Aarhus University Hospital & Aarhus University, Jens Chr. Skous Vej 4, 8000 Aarhus C, Denmark e-mail: [email protected] A. B. Jensen Department of Oncology, Aarhus University Hospital, Nørrebrogade 44, Bygning 5, 8000 Aarhus C, Denmark

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Keywords Breast cancer Faith, complementary and alternative medicine Cam Prevalence

Introduction In recent years, increased scientific attention has been paid to existential concerns when facing a life-threatening disease (Peterman et al. 2002) and turning to faith in God or a higher spiritual power appears to be a common way of coping with cancer (Koenig et al. 2001; Baider et al. 1999). Accordingly, a poll among a sample of healthy US citizens found that 79.6% reported getting comfort and strength from religion (Inglehart et al. 2004; World Value Survey 2009). Religious faith may serve the needs expressed by many cancer patients for finding meaning with their life, hope, existential resources, and to have someone to talk to about death and the process of dying (Moadel et al. 1999). Some patients may view their cancer to be a punishment from God, believe that God has an intended meaning with their cancer, or see religious faith as a potential curative factor, and their faith may thereby influence their decision-making regarding treatment in both beneficial and potentially harmful ways, for example through patient treatment delay (Thune´Boyle et al. 2006). Increased knowledge about various aspects of religious faith may help health professionals address patients’ existential concerns in relation to the course of disease and treatment. Improved understanding of the role of faith may also help managing differences between physicians and patients in their view on faith, a view that may potentially influence treatment adherence. While studies indicate that faith plays a considerable role among US patients (Pargament et al. 2004), little, so far, is known about cancer patients in other societies, secular societies in particular. Denmark is generally considered to be a highly secular society with faith being viewed as a private matter (Højsgaard and Raun Iversen 2005). Although the most recent report from Danish Ministry of Ecclesiastical Affairs shows that more recent 80.4% of Danes currently are members of the National Evangelical Lutheran Church (Ministry of Ecclesiastical Affairs 2011), surveys have found that 42.7% almost never attend religious services, 16% only attend on special holidays such as Christmas or Easter, with only 2% attending service once a week (Inglehart et al. 2004; World Value Survey 2009). Still, 76.5% of the Danes report themselves as being religious, with 68.9% indicating that they believe in God, 32.6% reporting that they receive comfort and strength from religion, and only 5.4% describing themselves as convinced atheists. In comparison, 82.5% of US citizens report being religious, 95.6% believe in God, 28.8% attend religious services at least once a week, and only 1.4% declare themselves as convinced atheists (World Value Survey 2009). Faith among patients in secular societies appears to be primarily practiced in a private and non-organized manner, an assumption that has found support in qualitative studies (Ahmadi 2006). That cancer patients from secular societies such as the Scandinavian countries are less likely to be found in church on Sundays may therefore not necessarily mean that they do not turn to their faith when confronted with a life-threatening disease. On the contrary, with 72% reported believers found in a study of 480 Danish hospitalized patients (Ausker et al. 2008), faith seems to be quite prevalent. The prevalence of faith among cancer patients in a secular society has, however, to our knowledge, not been reported so far. Furthermore, faith among healthy population samples has previously been assessed as a dichotomized yes/no construct (World Value Survey 2009). However, a more recent US study revealed that 62% of 1,844 cancer survivors reported being very

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religious, 27% slightly religious, and 11% not religious at all, suggesting the relevance of investigating the role of different degrees of religious conviction (Hsiao et al. 2008). Apart from a study of US cancer survivors showing that having prayed for their own health was most prevalent among women treated for breast cancer compared to other types of cancer patients (Ross et al. 2008), and qualitative data suggesting that faith may be particularly important to patients at the time of diagnosis and at more progressed stages of disease (Murray et al. 2004), not much is known about the role of cancer type and disease stage (Plante and Sherman 2001; McCullough and Larson 1998). Compared to more socio-economically resourceful citizens, US citizens having access to fewer socioeconomic resources have been found to exhibit greater emphasis upon faith at times of personal crisis. This includes ethnic minorities, single and older individuals, and people with lower educational and socio-economic status (Pargament 1997). The associations between socio-demographic factors and religious faith in cancer patients, however, are still largely unknown. The majority of research so far has focused on the role of faith in relation to general health and prognosis of disease (Stefanek et al. 2005), with health behaviors proposed as a primary mediator linking faith and health outcomes (Chida et al. 2009; McCullough et al. 2000). The available results suggest that faith is inversely associated with health risk behaviors such as alcohol consumption (Haber and Jacob 2007) and smoking (Timberlake et al. 2006). Faith has also been associated with improved physical functioning (Koenig et al. 2004), while the relationship with another often used health behavior indicator, the body mass index (BMI), is less clear, as previous results may be confounded by ethnicity and gender (Bruce et al. 2007). The use of complementary and alternative medicine (CAM) is another type of health behavior reported to be associated with faith (Pedersen and Zachariae 2008). The general trend of increased use of CAM among cancer patients internationally (Cassileth and Deng 2004) may at least in part be speculated to be the result of CAM being perceived as more patient-centered and holistic by addressing not only psychological, social, and physical, but also existential or spiritual needs (Smith et al. 2008). This view is supported by studies showing faith to be associated with increased CAM use among both cancer survivors (Hsiao et al. 2008) and healthy individuals (Smith et al. 2008), and other findings indicating that existential needs are important motivational factors for CAM use in general (Damkier 2000). Results from an US study also suggest that faith may be related to increased use of specific types of CAM (Hsiao et al. 2008). In this study, it was found that cancer survivors reporting any level of religiosity were less likely to use types of CAM defined as nonreligious/non-spiritual compared to non-religious cancer survivors, and those reporting any level of spirituality were more likely than non-spiritual cancer survivors to use types of CAM defined as non-religious/spiritual (Hsiao et al. 2008). In this instance, spirituality is defined as ‘‘an internal, personal, and emotional expression that arises from searching the sacred’’, whereas religiosity is defined as ‘‘the formal, institutional, and outward expression of the sacred’’ (Hsiao et al. 2008). These results are also based on data from US citizens and patients, and, at the present, there are no data available on the relationship between religious faith, CAM use, and other health behaviors in more secular societies. Taken together, most research on the role of religious faith in health and disease courses has been conducted in the USA, a society characterized by a high degree of self-reported and organized religiosity, and the generalizability of the available results to more secular societies such as the Scandinavian and other Northern European countries may therefore be uncertain. The objective of the present study was therefore to determine the prevalence of religious faith and to identify socio-demographic, clinical, and health-behaviour-related characteristics related to the degree of faith, including use of CAM, in a large nationwide cohort of Danish women treated for early-stage breast cancer.

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Patients and Methods Study Design and Materials The present study utilized data from the nationwide Psychosocial Factors and Breast cancer inception cohort of 4,917 Danish women treated surgically for early-stage breast cancer between October 2001 and March 2004 and allocated to one of the five existing standard treatment protocols as prescribed by the Danish Breast Cancer Cooperative Group (DBCG). Details concerning the PFAB cohort have previously been published (Christensen et al. 2009). Eligible women were informed about the study at the surgical departments, and the Charlson Comorbidity Index (Charlson et al. 1987) was completed for each patient. At baseline, 3–4 months post-surgery, all eligible women were mailed a questionnaire package, additional information, an informed consent form, and a prepaid return envelope, and invited to participate in the study. A hotline telephone and an e-mail service were offered to answer questions regarding the study and the filling of the questionnaire. If the questionnaires and the written consent were not returned within 3 weeks, a single reminder was sent. A total of 3,343 women (68.0%) returned a valid questionnaire. The majority of questionnaires (91%) were mailed out 3–4 months after primary surgery, and the remaining questionnaires were mailed out during the following 3 months. Responders were younger than non-responders (median 55.7 years vs. 58.0 years; range: 26–70 years). Age-adjusted analyses revealed that participation was not influenced by clinical factors, and the sample can therefore be considered as nationally representative with respect to disease- and treatment-related variables (Christensen et al. 2009). At follow-up 15–16 months post-surgery, 166 women, who had died or suffered a disease recurrence, and 47 women with unknown disease status at follow-up were excluded. Finally, 2 women were excluded because subsequently reported information showed that they did not meet the baseline inclusion criteria. Of the remaining 3,128 eligible recurrence-free women, 2,931 (94%) completed the follow-up questionnaire including questions concerning CAM use and religious conviction. Eighty-two of the excluded women having suffered a recurrence of the disease at follow-up had also completed a follow-up questionnaire. It was explored if these women differed with respect to religious faith from recurrence-free women. The study was approved by The Regional Science-Ethical Committees and The Danish Data Protection Agency. Eligibility Eligible patients were women, between 18 and 70 years of age, Danish residents, with histologically confirmed breast cancer T1-3, N0-3, and M0 according to the TNM (Tumor, Node, Metastasis) classification (Singletary et al. 2002) and no history of previous cancers, except non-melanoma skin cancer or carcinoma in situ of the cervix uteri. Additional requirements were ability to read Danish and being capable of completing a questionnaire. Data Collection Since 1968, all Danish residents have been assigned a 10-digit personal identification number (CPR-number) by the Danish Civil Registration System, which is used across all public registration systems, making linkages between a large number of registry-based data sources possible. Addresses, CPR-numbers, and data concerning eligibility, comorbidity,

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histopathology, and treatment-related variables were obtained directly from the surgical departments responsible for treating breast cancer in Denmark during the inclusion period, as well as from the DBCG-registry. The DBCG registry can be considered nearly complete. Validation studies suggest that at least 97% of all eligible women having had surgery for primary breast cancer in Denmark during the inclusion period were identified for the study (Rostgaard et al. 2000). Demographics, psychiatric history, and socio-economic variables were collected from six of the nationwide Danish longitudinal registries through a linkage serviced by Statistics Denmark (Statistics Denmark 2005). Further detailed information on health behaviors, health status, and psychosocial variables were obtained for the women in the questionnaire group. Assessment of Faith and Church Attendance Unambiguous faith, ambiguous faith, and no religious faith were measured at follow-up with the following item: ‘‘Do you believe in God or a higher spiritual power?’’ with the response options: (1) yes, (2) a little, and (3) no. Those indicating ‘‘yes’’ (indicating unambiguous faith) or ‘‘a little’’ (indicating ambiguous faith) were asked 2 additional questions: (a) ‘‘Do you believe this faith has had a positive influence on your quality of life in relation to your illness?’’ and (b) ‘‘Do you believe this faith has had a positive influence on the breast cancer disease?’’ with response options: (1) no, (2) a little, (3) somewhat, (4) a great deal, and (5) very much. Church attendance was assessed by responses to the question: ‘‘How often (approximately) have you attended church or other types of religious service within the past year? (If the occasion was family or friends’ christening, confirmation, wedding, or funeral, it should not be counted)’’ Response options were (1) never, (2) 1–3 times, (3) 4–10 times, and (4) more than 10 times. Assessment of CAM Use Use of CAM within the past year was assessed at follow-up with an adapted version of the Danish Health and Morbidity Survey (Rasmussen 1988; Kjøller and Rasmussen 2002). The question was phrased: ‘‘Have you used any of the following alternative treatments since you responded to the first questionnaire about one year ago?’’ The participants were asked whether they had used one or more of the following types of CAM: (1) Herbal medicine; (2) Reflexology; (3) Relaxation or yoga; (4) Kinesiology; (5) Dietary/exercise counseling; (6) Healing, laying on hands, or similar; (7) Massage/manipulation; (8) Meditation; (9) Needle acupuncture; (10) Dietary or vitamin supplement beyond ordinary vitamin pills; or (11) Other types (specified). When possible, the last variable was subsequently recoded independently and negotiated by two investigators into one of the 10 listed types of CAM. ‘‘No CAM use’’ was assessed with the control item: ‘‘No, I have not used any type of complementary or alternative treatment since I responded to the first questionnaire’’. CAM users were also asked: ‘‘Do you believe that the alternative therapy you have received will have a positive effect upon the breast cancer illness itself?’’ with response options: (1) no, not really, (2) possibly, (3) yes, relatively certain, and (4) yes, absolutely certain. Covariates Covariates included socio-demographic variables of personal income, mean household netwealth, occupational status, educational level, marital status, number of children, ethnicity,

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urbanicity, and psychiatric history, using relevant national registries (see Christensen et al. 2009 for further details). These variables all refer to pre-cancer conditions either in the year prior to the date of surgery minus 1 month or, when appropriate, at the date of surgery minus 1 month. Additional covariates included the weighted index score of the Charlson Comorbidity Index (CCI) obtained from the surgical departments (Charlson et al. 1987; Extermann 2000a, b). The 10-item Physical Functioning subscale (PF) of the MOS Short Form (SF-36) (Ware and Sherbourne 1992), information regarding BMI categorized according to WHO guidelines (World Health Organization 2000), smoking, and alcohol consumption presented in units per day (beers, glasses of wine, or drinks) were obtained 3–4 months post-surgery. Statistical Analysis Missing values were substituted on the SF-36 PF subscale only, with the mean of the remaining completed items if 50% or more of the items were filled as also recommended in the manual (Ware and Sherbourne 1992; Schafer and Graham 2002). Unadjusted associations with faith were assessed by chi2-tests. Subsequently, a multinomial logistic regression model was used to evaluate the association of each variable with unambiguous and ambiguous faith using no faith as reference while adjusting for the influence of age entered as a continuous variable. Covariates were only considered statistically significant if confirmed (P \ 0.05) by the chi-square statistics of the likelihood ratio test indicating that the addition of the covariate resulted in an improved fit. Results are presented as adjusted odds ratio (OR). Age-adjusted binary logistic regression analysis with ambiguous faith as category of reference were used to evaluate the perceived influence of faith on QOL and the course of cancer because women from the ‘‘no faith’’ group were not eligible for this analysis. All analyses were conducted with SPSS 16.0.1 for Windows.

Results A total of 3,128 women were eligible for the present study at follow-up whereof 2,920 responded to questions regarding faith. Of these, 1,382 (47.3%) reported having unambiguous faith in God or a higher spiritual power, 1,049 (35.9%) indicated having ambiguous faith, and 489 (16.7%) reported having no religious faith. As seen in Table 1, univariate analyses showed faith to be significantly related to most of the socio-demographic variables including age, with the exception of marital status and mean household net-wealth. Regarding history of physical and mental disease, there was no significant association between faith and physical comorbidity or psychiatric history. Women having unambiguous faith were older compared to non-believers. When adjusting for age in multinomial logistic regression analyses, women with ambiguous faith were more likely to be married or cohabiting and having lower income compared to nonbelievers and less likely to be immigrants when compared to unambiguous believers. When compared to women having ambiguous or unambiguous faith, non-believers had more years of education, were less likely to have children, and were more likely to live in the metropolitan area of Copenhagen. Although univariate tests showed faith to be associated with menopausal status and chemotherapy, no disease- or treatment-related factors were associated with faith in the age-adjusted analysis (Table 2). Women who had suffered a relapse and who had responded to the questionnaire (N = 82) did not differ with respect to religious faith from

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21.8

40.4

35.9

36–49

50–59

60–69

11.6

5.2

5.9

Divorced, separated, or married—single

Widow—single

Unmarried—single

89.2

Yes

38.7

26.7

4.8

Tertiary \ master degree (14–17 years)

Tertiary master degree (C18 years)

Lower secondary general (8–10 years)

Upper secondary (11–13 years)

17.3

12.5

Lower secondary general (7 years)

Education (ISCED 97 based)

10.8

No

Children

77.3

Married or cohabiting

Marital status

2.0

18–35

Agea

3.8

21.9

41.5

16.1

16.7

90.5

9.5

4.0

5.8

12.1

78.0

29.6

37.2

30.7

2.6

8.6

26.7

38.5

13.8

12.3

83.8

16.2

7.4

5.3

14.3

73.0

28.4

37.2

30.5

3.9

(95% CI)

1.36–4.65

1.17–3.97

0.77–2.64

Referent

5.1

25.0

39.7

14.0

16.3

0.51

0.89

0.86

0.80

1.00

0.31–0.84

0.62–1.29

0.61–1.21

0.53–1.21

Referent

Chi2(8) = 30.4; P \ .001 P \ .001

1.13–2.05

Referent 1.52

1.00 88.8

11.2

Chi2(2) = 13.0; P = .001

P \ .001

0.57–1.30

0.44–1.14

0.55–1.02

Referent

0.86

0.71

0.75

1.00

Chi2(6) = 15.7; P = .02

2.51

2.16

1.42

1.00

Chi2(6) = 38.9; P \ .001

OR

Age-adjusted

Unambiguous faith

Multinomial logistic regression

5.5

5.5

12.2

76.8

P = .07

32.4

38.7

26.4

2.5

P \ .001

%

%

%

%

N = 2,920

Ambiguous faith N = 1,049

Unambiguous faith N = 1,382

Nonbeliever N = 489

Total

Univariate analysis

Table 1 Socio-demographic and health-related predictors of faith

0.33

0.62

0.82

0.89

1.00

1.80

1.00

0.53

0.96

0.79

1.00

1.57

1.51

1.52

1.00

OR

0.19–0.57

0.42–0.91

0.57–1.16

0.58–1.36

Referent

1.31–2.48

Referent

0.33–0.84

0.59–1.56

0.57–1.08

Referent

0.84–2.92

0.82–2.78

0.82–2.82

Referent

(95% CI)

Age-adjusted

Ambiguous faith

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123

5.7

9.9

Old age pension

Recipients of early retirement pension, rehabilitation- or sickness benefits

16.2

20.1

20.7

24.5

18.5

B20.000 $

[20.000 $ and B30.000 $

[30.000 $ and B40.000 $

[40.000 $ and B55.000 $

[55.000 $

Personal income

17.9

20.9

Unemployed, recipient of temporary allowance-, cash- or pre-retirement benefits etc.

17.0

27.7

22.3

18.5

14.4

7.5

5.2

3.4

4.2

Self-employed or assisting spouse

11.4

27.0

8.9

22.8

Employee—basic level

10.4 17.3

Employee—others or in education

11.8

15.7

Employee—medium level

13.9

24.2

30.5

16.8

15.4

13.1

8.8

4.1

16.8

3.7

9.4

22.3

20.9

18.9

26.7

20.6

18.7

15.1

P = .001

8.8

5.3

19.1

3.8

9.9

24.2

17.2

11.7

P = .009

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

Top manager or employee—upper level

Occupational status (ISCO-88 based)

Table 1 continued

(95% CI)

Referent

0.69–1.72

0.56–1.91

0.77–1.70

0.67–2.24

0.69–1.68

0.86–1.76

0.63–1.33

0.76

0.80

1.19

1.10

1.00

0.52–1.09

0.56–1.14

0.81–1.74

0.75–1.61

Referent

Chi2(8) = 17.6; P = .02

1.09

1.03

1.14

1.23

1.08

1.23

0.92

1.00

Chi2(14) = 16.9; P = .26

OR

Age-adjusted

Unambiguous faith


0.67

0.86

1.25

1.11

1.00

1.06

1.44

1.31

1.21

1.60

1.62

1.12

1.00

OR

0.45–0.98

0.60–1.25

0.84–1.86

0.74–1.64

Referent

0.65–1.74

0.76–2.75

0.86–1.99

0.64–2.31

1.01–2.52

1.12–2.36

0.76–1.65

Referent

(95% CI)

Age-adjusted

Ambiguous faith

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18.3

23.5

21.7

C20.000 $ and \55.000 $

C55.000 $ and \120.000 $

C120.000 $

8.8

Copenhagen—Center

3.8

Immigrant or descendant

92.7

7.3

No

Yes

Psychiatric history

96.2

Not immigrant or descendant

Ethnicity

14.0

Copenhagen—Suburbs

5.2

94.8

1.8

98.2

8.4

15.0

21.3

5.7

94.3

3.3

96.7

13.1

22.1

19.3

6.3

93.7

P = .10

3.0

97.0

P = .02

9.4

15.7

21.4

0.38–0.85

0.36–0.73

0.67–1.35

0.73–1.38

Referent 0.66–2.07

1.33

1.00

0.86–2.05

Referent

Chi2(2) = 5.1; P = .08

1.17

1.00

Chi2(2) = 8.7; P = .01

0.57

0.51

0.95

1.00

Referent

22.2

30.3

1.00

50.000–300.000

39.1

36.8

16.8

37.3

10.000–50.000

15.2

17.8

\10.000 Inhabitants 16.2

Chi2(8) = 34.2; P \ .001

0.80–1.57

0.95–1.83

0.74–1.43

P \ .001

1.32

1.03

0.92–1.81

Referent

Urbanicity

22.1

19.1

1.29

1.00

1.12

20.1

19.5

20.5

(95% CI)

Chi2(8) = 5.0; P = .76

OR

Age-adjusted

Unambiguous faith


20.7

19.6

21.6

19.7

18.4

19.7

17.0

23.0

18.8

C0 $ and \20.000 $ 18.5

17.8

\0 $ 20.7

P = .16

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

Household net-wealth per person

Table 1 continued

0.92

1.00

0.55

1.00

0.60

0.63

1.03

1.20

1.00

1.01

1.17

1.03

1.17

1.00

OR

0.57–1.47

Referent

0.28–1.08

Referent

0.40–0.92

0.43–0.91

0.71–1.48

0.86–1.67

Referent

0.71–1.43

0.83–1.64

0.74–1.44

0.83–1.66

Referent

(95% CI)

Age-adjusted

Ambiguous faith

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123

8.6

1.2

CCI score [1 2.5

8.8

88.7 1.4

8.4

90.1

89.7 1.7

8.6

(95% CI)

0.65

0.92

1.00 0.27–1.61

0.64–1.34

Referent

Chi2(4) = 9.0; P = .06

OR

Age-adjusted

Unambiguous faith


1.66

1.03

1.00

OR

0.71–3.86

0.70–1.52

Referent

(95% CI)

Age-adjusted

Ambiguous faith

a

Not age-adjusted in the multinomial logistic regression

ISCED International Standard Classification of Education; ISCO-88 International Standard Classification of Occupation; OR odds ratio; CI confidence interval

% = Percent within faith subgroup in chi-square tests. Age-adjusted OR in bold differs significantly (95% CI) from the reference group (OR = 1.00) in multinomial logistic regressions using no faith as category of reference

90.3

CCI Score = 1

P = .16

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

No comorbidity

Charlson comorbidity index (CCI)

Table 1 continued

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33.0

15.1

[3

19.0

20.1

II

III

Non-ductal carcinoma

17.3

ER- and PR-negative

65.6

34.4

Post-menopausal

Pre-menopausal

Menopausal status

82.7

ER- and/or PR-positive

ER/PR receptorstatus

25.5

35.4

I

Tumor grade

51.9

1–3

2.3

0

Nodal status

[50 mm

61.7

36.0

B20 mm

40.2

59.8

16.6

83.4

16.8

21.1

36.3

25.8

17.0

33.7

49.2

3.2

35.0

61.8

44.1

55.9

16.2

83.8

22.3

18.2

37.8

21.7

17.1

33.8

49.1

4.1

34.4

61.5

38.1

61.9

P \ .001

16.9

83.1

P = .84

19.3

19.6

36.1

25.0

P = .08

16.1

33.4

50.5

P = .59

2.9

35.4

61.7

P = .33

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

[20 and B50 mm

Tumor size

Table 2 Clinical predictors of faith

(95% CI)

0.321.01

0.831.29

Referent

0.641.16

0.741.18

Referent

0.55–1.03

0.69–1.34

0.611.07

Referent

0.84–1.47

Referent

1.02

1.00

0.72–1.44

Referent

Chi2(2) = 0.8; P = .66

1.11

1.00

Chi2(2) = 0.6; P = .73

0.76

0.96

0.81

1.00

Chi2(6) = 11.0; P = .09

0.86

0.93

1.00

Chi2(4) = 2.2; P = .71

0.57

1.04

1.00

Chi2(4) = 4.1; P = .39

OR

Age-adjusted

Unambiguous faith


0.90

1.00

1.04

1.00

0.63

1.01

0.81

1.00

1.00

1.00

1.00

0.76

1.01

1.00

OR

0.63–1.29

Referent

0.78–1.39

Referent

0.45–0.88

0.72–1.41

0.611.08

Referent

0.741.35

0.791.27

Referent

0.431.35

0.801.27

Referent

(95% CI)

Age-adjusted

Ambiguous faith

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123

53.2

39.3

Treated with chemotherapy (CEF or CMF)

Treated with radiotherapy

63.7

In treatment with hormone therapy (TAM or TAM ? FEM)

64.9

35.1

79.4

20.6

43.6

56.4

53.3

46.7

65.1

34.9

80.4

19.6

45.4

54.6

55.0

45.0

64.4

35.6

P = .78

78.7

21.3

P = .29

41.9

58.1

P = .03

53.5

46.5

(95% CI)

0.75–1.14

Referent

0.82–1.35

Referent


0.95

1.00

0.77–1.19

Referent

Chi2(2) = 0.3; P = .86

0.86

1.00

Chi2(2) = 1.8; P = .42

1.05

1.00

Chi2(2) = 0.2; P = .91

0.92

1.00

Chi2(2) = 0.6; P = .74

OR

Age-adjusted

Unambiguous faith


0.99

1.00

0.95

1.00

1.02

1.00

0.93

1.00

OR

0.79–1.25

Referent

0.72–1.24

Referent

0.78–1.32

Referent

0.75–1.15

Referent

(95% CI)

Age-adjusted

Ambiguous faith

OR odds ratio; CI confidence interval


36.3

No hormone therapy

Hormone therapy

22.5

77.5

No radiotherapy

Radiotherapy

60.7

No chemotherapy

Chemotherapy

46.8

Mastectomy

P = .77

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

Lumpectomy

Type of surgery

Table 2 continued

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J Relig Health

those not suffering relapse in an age-adjusted multinomial logistic regression analysis (likelihood ratio test: chi2(2) = 0.78; P = . 68, data not shown). In the age-adjusted analyses, non-believers reported better physical functioning compared to women having unambiguous or ambiguous faith. Women having unambiguous faith were less likely to consume 3 or more units of alcohol per day (Table 3). A total of 53.7% of the women reported at least some influence of their faith on their quality of life, while 34.5% reported at least some perceived positive influence of their faith on the course of their breast cancer disease (data not shown). As shown in Table 4, women having unambiguous faith in God or a higher spiritual power were much more likely to perceive this faith to influence the course of their breast cancer with 27.6% answering ‘‘very much’’ or ‘‘a great deal’’ compared to 1.4% for ambiguous believers. Similarly, women having unambiguous faith were also much more inclined than women with ambiguous faith to perceive their faith as having a positive influence on their quality of life (47.6% vs. 3.4%, respectively). A total of 49.8% of the women had used one or more than one type of CAM within the past year. In the univariate analyses, type of faith was significantly associated to all specific types of CAM use, with the exception of massage, needle acupuncture, and reflexology. In the age-adjusted analyses, women having unambiguous faith were found to be more frequent users of all types of CAM except from massage, needle acupuncture, and reflexology when compared to non-believers. Women with unambiguous faith were also more likely to use massage and needle acupuncture when compared to women with ambiguous faith. Furthermore, women with unambiguous faith were much more likely to believe that their CAM use had a positive influence on the course of their breast cancer when compared to women with ambiguous religious faith and non-believers. A higher degree of believed effect of CAM use on the breast cancer illness was associated with increased perceived influence of faith on quality of life (rpb = . 278, P \ 0.001, and perceived influence of faith on the breast cancer itself, rpb = . 344, P \ 0.001 (data not shown). In all, 45.9% of the women reported to have been to church within the past year beyond attending christenings of children of friends or family, confirmations, weddings, or funerals, 30.2% had been to church 1–3 times, 8.4% 4–10 times, and 7.2% more than 10 times. Those having attended church were older than those not having attended church (1–3 times: OR: 1.02, P \ 0.001; 4–10 times: OR: 1.04, P \ 0.001; More than 10 times: OR: 1.05, P \ 0.001) (data not shown). Women classified as believers were more frequent church attendees than non-believers.

Discussion This first nationwide study of religious faith among cancer patients in a secular society shows that 83.2% of Danish women with breast cancer describe themselves as having either ambiguous or unambiguous faith in God or a higher spiritual power. The prevalence rate is only slightly lower than the 89% of US cancer survivors reporting to be either slightly or very religious (Hsiao et al. 2008), but higher than previously found in both healthy (World Value Survey 2009) and hospitalized (Ausker et al. 2008) Danish samples. Although the results thus are consistent with the literature suggesting that patients may turn to religious faith as a means of coping with potentially life-threatening illness, no diseaserelated factors were associated with faith in the present study and the prevalence of faith in our sample of recurrence-free women was not different when compared to the subgroup of

123

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30.6

5.4

12.7

9.1

Ex-smoker

1–9 per day

10–19 per day

C20 per day

5.8

40.9

25.0

11.5

6.1

Ex-drinker

\1 drink per day

C1 and \2 drinks per day

C2 and \3 drinks per day

C3 drinks per day

57.6

2.4

27.9

12.1

Normal weight ([18.5 and \25)

Underweight (B18.5)

Overweight (C25 and \30)

Obese or severely obese (C30)

Body mass index (BMI)

10.8

Never drinker

Alcohol

42.2

Never smoker

Smoking status

11.0

27.7

2.2

59.1

7.4

11.6

23.4

43.1

5.3

9.2

10.4

14.3

4.7

31.2

39.3

8.9

25.9

3.3

61.9

9.9

11.8

27.5

38.6

3.5

8.7

10.9

14.4

7.5

29.6

37.6

11.1

27.5

2.5

58.9

P = .36

7.2

11.6

24.9

41.3

5.2

9.9

P = .07

9.9

13.6

5.5

30.6

40.4

P = .26

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

Table 3 Faith and self-reported health behaviors, BMI and physical function

2

(95% CI)

0.55–1.14

0.57–1.09

0.40–0.95

0.72–1.20

Referent

Referent

0.29–0.78

0.48–1.20

0.50–1.11

0.64–1.39

0.79–2.80

1.39

1.10

0.74

1.00

0.97–2.00

0.86–1.40

0.40–1.36

Referent

Chi2(6) = 5.2; P = .51

0.47

0.76

0.75

0.94

1.49

1.00

Chi2(10) = 21.3; P = .02

0.79

0.79

0.61

0.93

1.00

Chi (8) = 9.3; P = .31

OR

Age-adjusted

Unambiguous faith


1.27

1.10

0.69

1.00

0.70

0.92

0.81

1.09

1.48

1.00

0.93

0.95

0.60

1.01

1.00

OR

0.87–1.86

0.85–1.42

0.36–1.33

Referent

0.42–1.16

0.57–1.49

0.53–1.23

0.73–1.64

0.77–2.85

Referent

0.64–1.35

0.68–1.33

0.38–0.95

0.78–1.32

Referent

(95% CI)

Age-adjusted

Ambiguous faith

J Relig Health

18.6

C0 and B70

15.9

17.5

22.6

27.4

16.6

11.3

13.8

28.0

25.8

21.0

16.4

16.4

25.7

25.0

2.20

1.71

1.42

1.31

1.00

1.51–3.21

1.19–2.46

1.04–1.93

0.95–1.80

Referent

Chi2(8) = 30.8; P \ .001

16.4

P \ .001

1.75

1.61

1.03

1.36

1.00

OR

1.18–2.59

1.11–2.34

0.74–1.42

0.99–1.88

Referent

(95% CI)

Age-adjusted

Ambiguous faith



27.3

16.5

[80 and B90

22.9

[90 and \100

[70 and B80

14.7

(95% CI)

OR

Age-adjusted

Unambiguous faith


%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

100

Physical function (SF-36 PF)

Table 3 continued

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20.0

27.4

20.2

A little

Somewhat

A great deal

Very much

16.4

16.9

10.7

A little

Somewhat

A great deal

Very much

37.3

34.5

13.8

14.4

Never

1–3 times

4–10 times

[10 times

Church attendance

43.0

13.0

No

Experienced positive effect of faith on course of breast cancera

17.6

14.9

No

Experienced positive influence of faith on QoLa 59.1

0.6

4.8

30.9

63.8

0.1

1.3

5.9

13.7

79.0

0.5

2.9

9.8

27.7

1.1

0.6

16.4

81.9

7.2

8.4

30.2

54.1

27.91

45.07

4.53

1.00

11.37–68.53

14.29–142.17

3.43–5.97

Referent

Chi2(6) = 512.5; P \ .001 P \ .001

28.47–1463.00

16.2–846.2

5.4–289.7

1.16–68.47

Referent

204.08

116.91

39.72

8.91

1.00

6.1

10.2

11.9

13.3

58.5

Wald (4) = 250.6; P \ .001

P \ .001

57.51–346.04

31.10–189.19

8.19–50.93

1.67–11.41

Referent

141.07

76.71

20.43

4.37

1.00

11.7

16.8

15.6

20.4

35.4

Wald(4) = 489.9; P \ .001

P \ .001

(95% CI)

OR

Age-adjusted

Unambiguous faith


%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

Table 4 Faith, church attendance, and use of individual CAM therapies

0.68

9.42

2.40

1.00

OR

0.21–2.23

2.92–30.43

1.82–3.18

Referent

(95% CI)

Age-adjusted

Ambiguous faith

J Relig Health

34.9

14.9

19.0

Yes, almost certain

Yes, absolutely certain

54.6

Yes

35.6

Yes

15.7

Yes

86.7

13.3

No

Yes

Herbal medicine

84.3

No

Massage

64.4

No

Dietary/nutrition supplements

45.4

No

CAM use

31.2

Possibly

9.9

90.1

12.3

87.7

27.2

72.8

45.9

54.1

9.4

11.8

38.0

40.8

8.8

91.2

13.8

86.2

26.2

73.8

44.7

55.3

9.7

9.2

33.3

47.7

1.00

Referent

11.3

88.7

P = .006

14.2

85.8

P = .06

31

69


0.95–1.73

Referent

1.77

1.00

1.24–2.53

Referent

Chi2(2) = 15.5; P \ .001

1.28

1.00

Chi2(2) = 9.2; P = .01

1.71

1.00

Chi2(2) = 34.7; P \ .001


P \ .001

1.00 1.66

49.8

50.2

Chi2(2) = 35.6; P \ .001

P \ .001

2.04–6.14

1.61–5.03

1.16–2.45

3.54

2.85

1.69

14.4

13.0

35.7

36.9

Chi2(6) = 48.3; P \ .001

P \ .001

(95% CI)

OR

Age-adjusted

Unambiguous faith


%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

No, not really

Believed positive effect of CAM on course of breast cancerb

Table 4 continued

1.16

1.00

0.89

1.00

1.08

1.00

1.08

1.00

1.21

1.58

1.36

1.00

OR

0.80–1.70

Referent

0.65–1.23

Referent

0.84–1.38

Referent

0.86–1.35

Referent

0.66–2.21

0.87–2.87

0.93–1.99

Referent

(95% CI)

Age-adjusted

Ambiguous faith

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11.7

10.4

Yes

9.3

Yes

10.6

Yes

91.1

8.9

No

Yes

Healing

89.4

No

Relaxation, yoga, or similar

90.7

No

Reflexology

89.6

No

Needle acupuncture

88.3

Yes

3.2

96.8

6.7

93.3

9.0

91.0

8.0

92.0

8.8

91.2

1.9

98.1

7.8

92.2

7.5

92.5

9.6

90.4

8.2

91.8

(95% CI)

(referent) 1.14–2.39

0.87–1.76

(referent)

(referent) 0.93–2.02

5.7

94.3

5.96

1.00

2.99–11.89

Referent

Chi2(2) = 63.4; P \ .001 P \ .001

Referent 1.01–2.16 1.48

1.00

Chi2(2) = 13.6; P = .001

1.37

1.00

Chi2(2) = 2.7; P = .27

1.24

1.00

Chi2(2) = 7.2; P = .03

1.65

1.00

Chi2(2) = 11.8; P = .003

OR

Age-adjusted

Unambiguous faith


8.7

91.3

P = .003

8.9

91.1

P = .50

9.4

90.6

P = .13

10.1

89.9

P = .021

%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

No

Nutrition/exercise counseling

Table 4 continued

1.80

1.00

0.87

1.00

1.24

1.00

0.84

1.00

1.11

1.00

OR

0.85–3.80

Referent

0.57–1.32

Referent

0.8–1.85

(referent)

0.57–1.23

(referent)

0.75–1.65

(referent)

(95% CI)

Age-adjusted

Ambiguous faith

J Relig Health

6.3

2.8

Yes

1.4

98.6

1.7

98.3

98.3

0.6

99.4

1.7

1.9

98.1 5.17

1.00

1.58–16.90

Referent

Chi2(2) = 14.9; P = .001


P \ .004

1.00 4.42

96.2 3.8

2.27

1.00

1.02

1.00

OR

0.65–7.94

Referent

0.44–2.38

Referent

(95% CI)

Age-adjusted

Ambiguous faith

b

CAM users only: N = 1,272

The age-adjusted OR are the results of a binary logistic regression with ambiguous faith as category of reference because women from the ‘‘no faith’’ group were not eligible for this analysis

a



97.2

No

Kinesiology

93.7

Yes

Chi2(2) = 48.4; P \ .001

P \ .001

(95% CI)

OR

Age-adjusted

Unambiguous faith


%

%

%

%

N = 2,920



Nonbeliever N = 489

Total

Univariate analysis

No

Meditation

Table 4 continued

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women with recurrent disease. It is therefore possible that the increased prevalence of faith among these women is caused by the experience of facing a potentially life-threatening disease, regardless of the objective severity of the disease (e.g. tumor size or axillary node involvement). Accordingly, only 40.8% of a sample of healthy Danish women reported getting comfort and strength from religion (World Value Survey 2009), whereas 53.7% in our cohort of women with breast cancer reported at least some influence of their faith on their breast cancer-related quality of life. In addition, more than a third (34.5%) of the women in the present cohort reported their faith to have had at least some kind of positive influence on the course of their breast cancer. Compared to non-believers, the women reporting faith were found to have lower educational level, which is consistent with previous findings (Pargament 1997). Furthermore, women living in the metropolitan area of Copenhagen were less likely to believe in God or a higher spiritual power. Consistent with the general association found between faith and increased marital fertility, and results indicating that the process of secularization may be associated with a decline in child births (Adsera 2006), women having faith in the present study were more likely to have children than non-believers. Also contrary to previous findings that believers have better physical functioning (Koenig et al. 2004), this present study found that women reporting faith experienced poorer physical functioning compared to non-believers. The role of secularization may be reflected in the fact that only 6.6% of a healthy Danish population sample reported God as being a very important part of their lives, compared to 58.3% of US citizens (World Value Survey 2009). Thus, although the overall prevalence of faith in the United States and Denmark are comparable, the nature of faith appears different. In our sample, 35.9% reported a little faith and 47.3% unambiguous faith in God or a higher spiritual power. In comparison, only 27% of a sample of US cancer survivors reported themselves to be ‘‘slightly religious,’’ while 62% were ‘‘very religious’’ (Hsiao et al. 2008), which indicates a lower prevalence of unambiguous faith in our sample of breast cancer patients from a secular society. With respect to the perceived role of faith, a large difference was found between women having unambiguous faith and those reporting only little faith. Compared to only 3.4% of the ambiguous believers, nearly half (47.6%) of the unambiguous believers thought that their faith had a large (‘‘a great deal’’ or ‘‘very much’’) positive effect on their cancerrelated quality of life. Perhaps even more strikingly, 27.6% of the unambiguous believers, compared to only 1.4% ambiguous believers, reported that they believed that their faith have had a positive effect on the course of their breast cancer. This is the first study to demonstrate that women having unambiguous faith are experiencing faith to have a much larger positive influence on both their quality of life in relation to their illness and on the course of breast cancer illness compared to ambiguous believers. This finding indicates the relevance of differentiating between different degrees of conviction rather than on religiosity as a dichotomized construct. Unambiguous faith, but not ambiguous faith, was also positively associated with the use of the majority of different CAM types and with a markedly higher degree of believed positive effect of CAM on the course of breast cancer among CAM users. Furthermore, the belief that CAM could have an influence on the breast cancer was found to be positively associated with a higher degree of perceived influence of faith on both breast cancerrelated quality of life and the course of breast cancer. Our results thereby support previous findings of US studies, indicating faith to be related to increased the use of CAM (Hsiao et al. 2008; Smith et al. 2008). The results further reveals that among Danish breast cancer patients, it is only unambiguous faith—not ambiguous faith—that is associated with use of

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CAM. Our results could indicate that CAM may be used especially by women having unambiguous faith perhaps as a means of complying with systems of beliefs asserting that God or a higher spiritual power may intervene and influence the course of breast cancer and individual well-being. This view is supported by previous research identifying existential needs as an important motivational factor for CAM use (Damkier 2000). Although we have no data on this aspect, it may also be speculated that the convictions associated with unambiguous faith could have implications for adherence to conventional treatment and for the quality of physician-patient communication due to the potential incompatibilities between scientific and religious-based systems of belief. Only 7.2% of the women had attended church more than 10 times within the past year since the time of diagnosis, beyond for formal reasons such as weddings and christenings. While this may seem surprising, given that a cancer diagnosis could be regarded as a time of crisis, the results are consistent with previous findings that, although the majority of Danes are members of the National Evangelical Lutheran Church (Ministry of Ecclesiastical Affairs 2011), they tend to practice their faith in a more private and non-organized manner (Højsgaard and Raun Iversen 2005). It may be speculated that the intensity of faith in the secular society is limited with respect to influencing activities and ways of living. The results of a recent qualitative study of Swedish cancer patients suggest that faith in a secular society may be characterized by being more spiritually than religiously oriented (Ahmadi 2006). While both spiritual and religious faith could be interpreted as a search for meaning in ways related to the sacred (Pargament 1997), religiosity generally refers to the practice of faith within a structured system of beliefs associated with specific rituals, whereas spirituality is interpreted as a universal phenomenon that exists both within and outside traditions systems of faith and is practiced in individual and personal ways (Peterman et al. 2002). Population studies of changes in faith in Denmark over the last 50 years suggest that older individuals are more inclined to have faith in a personal God, whereas younger people are more likely to believe in a spiritual power (Højsgaard and Raun Iversen 2005). Our results showing that unambiguous faith was more prevalent among older patients could thus be interpreted either as an expression of a cohort effect or—in concordance with results from US studies—as suggesting that faith becomes more important at the end of life (Koenig et al. 1998). Finally, it should be noted that responders in the present study were slightly younger, had more education, and better physical functioning than non-responders (Christensen et al. 2009), which indicates a potential bias in the direction of underestimating the true prevalence of religious faith.

Conclusion This first nationwide study of faith among cancer patients in a secular society revealed that women with breast cancer having unambiguous religious faith express a markedly higher degree of certainty that their held system of belief may play a positive role in relation to the course of their breast cancer and cancer-related quality of life when compared to women reporting ambiguous faith. This unambiguous conviction was further related to use of CAM and to the belief that CAM has a positive effect on the breast cancer. Although relatively few breast cancer patients attended church, more than 8 of 10 women had at least some faith in God or a higher spiritual power. Overall faith thus appears equally prevalent among Danish and US breast cancer patients. However, the majority of Danish breast cancer patients experience ambiguous faith, whereas the majority of US breast cancer

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patients express unambiguous faith. Furthermore, it seems important for future studies to distinguish more clearly between ‘‘faith in God’’ and ‘‘faith in a higher spiritual power’’ in order to clarify questions related to effects of faith in secular societies. Future studies may also benefit from exploring issues concerning the role of faith and spirituality in relation to adherence to conventional treatment and health behaviors, including CAM use. Acknowledgments We thank participating women and the staff at the 24 participating surgical departments. We also thank Susanne Møller, the Danish Breast Cancer Cooperative Group (DBCG), Rigshospitalet, Copenhagen University Hospital, for providing the clinical data.

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