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A Pilot Study Addressing the Impact of Religious Practice on Quality of Life of Breast Cancer Patients During Chemotherapy

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A Pilot Study Addressing the Impact of Religious Practice on Quality of Life of Breast Cancer Patients During Chemotherapy
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  ORIGINAL PAPER A Pilot Study Addressing the Impact of ReligiousPractice on Quality of Life of Breast Cancer PatientsDuring Chemotherapy Carlos Eduardo Paiva  • Bianca Sakamoto Ribeiro Paiva  • Rafael Amaral de Castro  • Cristiano de Pa´dua Souza  • Yara Cristina de Paiva Maia  • Jairo Aparecido Ayres  • Odair Carlito Michelin Published online: 20 January 2011   Springer Science+Business Media, LLC 2011 Abstract  The aim of this preliminary study was to investigate whether religious practicecan modify quality of life (QoL) in BC patients during chemotherapy. QoL and religionpractice questionnaire (RPQ) scores were evaluated in a sample of BC patients in differentmoments. Before chemotherapy initiation, women with lower physical and social functionalscores displayed higher RPQ scores. On the other hand, low RPQ patients worsened someQoL scores over time. Body image acceptance was positively correlated with religiouspractice and specifically praying activity. This preliminary study suggests the importance of religion in coping with cancer chemotherapy. Keywords  Breast cancer    Coping    Religiosity    Quality of life    Oncology   Chemotherapy C. E. Paiva ( & )Palliative Care Unit, Hospital de Caˆncer de Barretos, Unidade II, Rua 20, 221, Centro, Barretos,Sa˜o Paulo 14780-070, Brazile-mail: caredupai@gmail.com; carlospaiva@hcancerbarretos.com.brB. S. R. PaivaDepartment of Public Health, Botucatu Medical School,Sa˜o Paulo State University (UNESP), Botucatu, Sa˜o Paulo, BrazilR. A. de Castro    C. P. SouzaOncological and Hemato-oncological Center, Botucatu Medical School,Sa˜o Paulo State University (UNESP), Botucatu, Sa˜o Paulo, BrazilY. C. de Paiva MaiaLaboratory of Nanobiotechnology, Federal University of Uberlaˆndia (UFU),Uberlaˆndia, Minas Gerais, BrazilJ. A. AyresDepartment of Nursing, Botucatu Medical School,Sa˜o Paulo State University, UNESP, Botucatu, Sa˜o Paulo State, Brazil O. C. MichelinDepartment of Internal Medicine, Botucatu Medical School,Sa˜o Paulo State University (UNESP), Botucatu, Sa˜o Paulo, Brazil  1 3 J Relig Health (2013) 52:184–193DOI 10.1007/s10943-011-9468-6  Introduction Breast cancer (BC) is the most common malignancy affecting women worldwide (Carlsonet al. 2010). It affects quality of life (QoL) at diagnosis, during treatment, and even afterrecovery (Purnell et al. 2009).Cancer chemotherapy clearly improves survival of BC patients, both in adjuvant and inmetastatic settings (Carlson et al. 2010). In addition to survival, QoL is another importantendpoint in modern oncology. Moreover, identifying factors associated with better QoLduring cancer chemotherapy is of utmost importance.Religion and spirituality are resources frequently used by patients as part of theirstrategy for coping with chronic disease diagnosis and treatment (Purnell et al. 2009;Campbell et al. 2010). Religion is a common coping strategy used by BC patients (Johnsonand Spilka 1991).The aim of this preliminary study was to investigate whether religious practice canmodify QoL in Brazilian BC patients during chemotherapy. Methods DesignThis observational study was conducted at the Oncological and Hemato-oncological Centerof Sa˜o Paulo State University, Botucatu-SP, Brazil, between March 2009 and December2009. Subjects were assessed at the start of chemotherapy (T0), after two cycles of che-motherapy (T1) and after four cycles of chemotherapy (T2). Patients aged [ 18 years, witha diagnosis of BC, and starting doxorubicin-based chemotherapy were eligible for thisstudy if they: (1) were chemotherapy-naive, (2) had not been submitted to radiotherapy, (3)had not been diagnosed with any other cancer in the past, (4) had no obvious cognitivedeficit or significant psychiatric problems (e.g. psychosis). Socio-demographic dataincluded age, educational level, marital status, religious preference, and the presence orabsence of a living partner. Clinical data, extracted from case records, consisted of diseaseclinical stage, pathological information, and initial management. The Ethics Committeeapproved the study (CEP-FMB 3097/2009), and all interviews were carried out withpatients’ permission.InterventionAfter giving their informed consent, the patients were interviewed by a clinical oncologist(CEP, RCA, CP) or a research nurse (BSRP). In the first consultation (T0), information wascollected addressing socio-demographic and clinicopathological data. Religious practiceand QoL parameters were assessed at different moments (T0, T1, and T2). Thirty-twopatients with BC diagnosis were submitted to chemotherapy during the study period. Threepatients were excluded from the study because they did not match inclusion criteria andtwo others refused to participate in the study. Twenty-seven patients were interviewed(  N   =  27). Some patients entered the study during preoperative chemotherapy but had justone or two interview consultations because of disease progression during therapy. Wedecided not to obtain information from these patients after surgery. Twenty-three (23/27,85%) and 18 (18/27, 67%) of the patients had two (T0 and T1) and three (T0, T1 and T2)interviews, respectively. J Relig Health (2013) 52:184–193 185  1 3  Measures(1) Socio-demographic data were provided by the patients during interviews. For statisticalpurposes, we considered altogether as ‘‘Spiritualists’’ those who believe in the reincarna-tion theory and in the presence of spirits.(2) Medical data (histology subtype, TNM clinical stage, and initial management) wereextracted from the patient’s medical record using a brief protocol.(3) Religious practice was measured using the Religion Practice Questionnaire (RPQ), astandardized self-reported measure of religiosity, proposed and validated in the Brazilianpopulation (Aquino et al. 2009). The RPQ consists of 15 items rated on a 5-point Likert-type scale (0—none to 5—much). The answers (0 up to 5) were summed and then dividedby 15 to reach the final result. Scores range from 0 to 5, with higher scores reflecting highervalues placed upon religious practice (Table 1).(4) QoL was measured by the generic 30-item questionnaire European Organization forResearch and Treatment of Cancer (EORTC) QLQ-C30, which had been already validatedfor use in Portuguese. It analyzes QoL by means of five functional subscales (physical,role, cognitive, emotional, and social); a global health/QoL subscale; three symptomsubscales (fatigue, pain, and nausea/vomiting); and single items for the assessment of additional symptoms commonly reported by cancer patients (dyspnoea, appetite loss, sleepdisturbance, constipation, and diarrhea) (Fayers et al. 1999; Aaronson et al. 1993). (5) Breast cancer-specific QoL was measured using the EORTC supplementary moduleEORTC-QLQ-BR23, consisting of 23 items that address functional and symptom scales(Fayers et al. 1999). Table 1  Questions (q) containedin the Brazilian ReligiousPractice Questionnaire (RPQ)(Aquino et al. 2009)Numbers Questionsq.1 I read the holy scriptures (Bible or other)q.2 I am used to reading books in which the matter isGodq.3 I try to know doctrines and principles of my religionq.4 I participate in debates about matters regardingreligionq.5 I talk to my family about religious issuesq.6 I watch TV or listen to radio programs thatconcern religion issuesq.7 I talk with my friends about my religiousexperiencesq.8 Religion influences my decisions about what to doq.9 I participate in collective prayers of my religionq.10 I attend celebrations of my religion (Mass, worship)q.11 I make personal prayers (spontaneouscommunications with God)q.12 I act according to what my religion prescribes as beingcorrectq.13 I feel united with all thingsq.14 When I enter in a Church or Temple I feel emotionalq.15 I feel attached to a higher being186 J Relig Health (2013) 52:184–193  1 3  Statistical AnalysesWe defined the median value (2.6) as the cutoff point between low and high levels of religious practice. The Kruskal–Wallis or Mann–Whitney test was applied to comparedifferent QoL scores between the low and high religious practice groups and different RPQscores in relation to different variables (age, clinical stage, ethnic status, marital statusreligious preference, ECOG performance status, financial income, educational level,presence or absence of living partners, and type of surgery). Correlation analyses for QoL(EORTC-QLQ-C30 and EORTC-QLQ-BR23) scores and RPQ score were carried outusing Spearman’s rank test. Question number 11 (q.11) ‘‘I make personal prayers (spon-taneous communications with God)’’ was correlated with both QoL questionnaires. Aminimum level of significance of 0.05 was used for all analyses. The statistical analyseswere carried out using GraphPad Prism3 (GraphPad Software Inc., La Jolla, CA, USA). Results Religious Practice Questionnaire (RPQ) ScoresThe RPQ was easily answered by all the patients, with the exception of question 13 (q.13)‘‘I feel united with all things,’’ which was frequently not understood by patients. Althoughour results did not change significantly regarding the inclusion or exclusion of q.13, wedecided not to use q.13 in the final analysis. The RPQ scores were significantly correlatedat the different moments (  N   =  17) (T0 vs. T1,  r   =  0.62,  P  =  0.0077; T0 vs. T2,  r   =  0.72, P  =  0.0010; T1 vs. T2,  r   =  0.75,  P  =  0.0005).There were no statistical significant differences in median RPQ scores in relation to age( \ 50 years vs.  C 50 years), clinical stage (I–III vs. IV), ethnic status (Caucasian vs. non-Caucasian), financial income ( \ 1 vs. 1–4 vs. [ 4 times the minimum wage), years of schooleducation ( \ 8 years vs. 9–11 years vs.  [ 11 years), marital status (married vs. non-married), performance status (ECOG 0 vs. 1), living with partners (husband vs. husbandand children vs. children vs. other family member vs. living alone), or surgery (mastec-tomy vs. conservative surgery vs. no surgery). On the other hand, Catholics and Protestantspresented higher RPQ scores than ‘‘Spiritualists’’ (3.27 vs. 3.57 vs. 2.67, respectively, P  =  0.05) (Table 2).Correlation Analysis Between Age and Religious Practice Questionnaire (RPQ) ScoresThere was no correlation between age and RPQ scores (  N   =  67,  r   = - 0.0005,  P  =  0.99).Correlation Analysis Between EORTC-QLQ-C30 and Religious Practice Questionnaire(RPQ) ScoresWhen considering only moment T0 (  N   =  27)—immediately before the first chemotherapycycle—we found a significant negative correlation between physical functioning and RPQscore ( r   = - 0.4474,  P  =  0.0193). The same was observed regarding social functioning( r   = - 0.4614,  P  =  0.0154). A significant positive correlation was found between theglobal symptom scale and RPQ score ( r   =  0.5097,  P  =  0.0066), as well as some of itssubscales: fatigue ( r   =  0.4444,  P  =  0.0202), nausea and vomiting ( r   =  0.4370, P  =  0.0227), pain ( r   =  0.5083,  P  =  0.0068), and appetite loss ( r   =  0.5469,  P  =  0.0032). J Relig Health (2013) 52:184–193 187  1 3  There were no significant correlations between RPQ scores and the domains global healthstatus and global functional scales (Table 3). The emotional and cognitive functionalsubscales roles and the symptom subscales dyspnoea, insomnia, constipation, diarrhea, andfinancial difficulties were not correlated with RPQ scores (Table 3). Table 2  Association betweenReligious Practice Questionnaireand clinical characteristics  RPQ  Religious PracticeQuestionnaire,  TNM   tumor nodemetastasis,  ECOG  EasternCooperative Oncology Group.* Protestant vs. Spiritualistic, P  =  0.0095 (Mann–Whitneytest). Different words (a,b) implydifferent statistical results by theMann–Whitney test. # Includingsingle, separated, divorced, andwidowedCharacteristics RPQ Median (min–max)  P Age (years)  0.938 [ 50 3.33 (2.40–4.26) \ 50 3.33 (2.40–4.60) Clinical stage (TNM)  0.457I-III 3.20 (2.4–4.6)IV 3.73 (3.33–4.00) Ethnic status  0.778Caucasian 3.33 (2.40–4.26)Non-Caucasian 3.46 (2.43–3.66) Financial income (minimum wage)  0.712 \ 1 2.73 (2.40–4.6)1–4 3.33 (2.40–4.26) [ 4 3.47 (2.60–4.40) Educational level (years)  0.342 \ 8 years 3.20 (2.40–4.60)9–11 years 3.46 (3.06–4.20) [ 12 years 3.60 (3.20–4.40)  Marital status  0.7524Marriage 3.30 (2.40–4.26)Not marriage# 3.46 (2.40–4.60)  Religious preference  0.055Catholic 3.26 (2.40–4.60) a,b Protestant 3.56 (3.30–4.20) a *Spiritualistic 2.66 (2.46–3.2) b * Performance status (ECOG)  0.2280 3.74 (3.46–4.60)1 3.27 (2.40–4.20  Living with  0.446Husband 3.30 (2.53–4.26)Husband and children 2.27 (2.40–4.20)Children 3.17 (2.40–4.40)Other family members 3.93 (3.20–4.00)No one else (living alone) 4.03 (3.46–4.60) Surgery  0.146Mastectomy 3.20 (2.40–3.60)Conservative surgery 3.20 (2.46–4.40)No surgery 3.66 (2.40–4.60)188 J Relig Health (2013) 52:184–193  1 3
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