Physical, Psychological, Social, and Spiritual Well-being of Patients and Caregivers Following Lung Cancer Diagnosis: A Scoping Review

Background: Lung cancer is the second most common cancer in the United States and has been shown to cause considerable symptom burden in both patients and their caregivers. Recently, studies have focused on quality-of-life (QOL) measures and the relationship with health outcomes.

Objective: The objective of this scoping review was to investigate and analyze articles related to lung cancer patient and caregiver physical, psychological, social, and spiritual well-being to provide an evidence base for the development of an integrative digital education platform.

Methods: A 3-step search strategy was undertaken: (1) an initial limited search of PubMed and MEDLINE; (2) an extensive search using all identified keywords and index terms across all included databases; and (3) a hand search of the reference lists of included articles.

Results: A total of 1610 articles were screened, 205 full-text publications were reviewed, and 50 relevant articles were identified. Most studies focused on physical and psychological well-being. Several review articles discussed treatment algorithms and consideration for treatment of patients with lung cancer. Most of the articles evaluating the patient/caregiver relationship were related to the psychological component.

Conclusions: The most commonly evaluated QOL components were physical and psychological well-being, whereas only a single article discussed spiritual well-being. Additional research is needed related to QOL components in caregivers of patients with lung cancer. Inclusion of all 4 QOL components will be beneficial for developing a digital patient education platform for patients and their caregivers following a diagnosis of lung cancer.

Lung cancer, the second most common cancer and the primary cause of cancer-related death for Americans, invokes a higher symptom burden than other cancers.¹ Studies have demonstrated a link between well-being, symptom burden, and quality of life.^1-3 When patients receive a diagnosis of lung cancer, they face many cognitive and emotional challenges.⁴ However, the emotional and psychological impact of lung cancer on newly diagnosed patients is not well understood.

Caregivers, including family and friends, have been shown to be crucial for providing care for patients who have advanced cancer,^5,6 but this often leads to a burden that negatively impacts both QOL and the mood of caregivers.^7-9 At times, caregivers report psychological distress that exceeds the burden faced by patients with cancer, which highlights the importance of evaluating the psychological well-being of caregivers of patients with cancer.^10,11 As a patient’s disease progresses, the physical well-being of the caregiver has been shown to decrease.⁶ Additionally, caregivers experience social demands related to relationships, social support, and financial burden,¹² supporting the need to better understand caregiver burden and QOL.

People with a new cancer diagnosis, including non–small cell lung cancer (NSCLC), make many visits to doctors, imaging centers for scans, and laboratories for testing. Waiting for test results can be challenging for physicians, patients, and caregivers because there is a sense of urgency to start treatment. In one study, almost 20% of patients with NSCLC who had EGFR or ALK mutations started chemotherapy before biomarker results became available.¹³ However, studies indicate that delaying treatment for several weeks while additional testing is being performed does not affect outcomes.^14,15

To improve this waiting period for patients and their caregivers, it is important to make the time productive and meaningful. Instead of sitting at home, ruminating over the diagnosis and waiting for treatment, we can hand back some options for patients to empower them and influence their cancer trajectory. The loss of control, distress, anxiety, and depression, which often follow a cancer diagnosis, may then be tackled in part by assigning tasks to the patient in the time between diagnosis and first treatment.¹⁶

Following a diagnosis, healthcare providers and patients work together to determine a course of care that is aligned with the patients’ values in a shared decision-making process. When patients participate in the decision-making process, studies have reported increased trust, more realistic perceptions of risk and treatment expectations, improved patient-reported and clinical outcomes, and increased treatment adherence and patient satisfaction.^17,18 The initial step required in the complex shared decision-making process is to acquire the knowledge to support both value- and preference-based decisions, which can be achieved via evidence-based educational tools.

Patient education has been shown to improve knowledge; facilitate understanding of the disease, including risk factors, prognosis, and the risk/benefit profile of treatments; improve cognitive skills, including self-efficacy and problem-solving; and facilitate communication.¹⁹ Family, caregivers, and social networks can also influence health decisions. Health education should be designed to consider patient benefits, barriers, and external influences from healthcare providers and family members to enhance productive behaviors, including adherence and self-care, which have been shown to improve patient outcomes.²⁰ The Cancer Advocacy & Patient Education (CAPE) initiative aims to create a web-based library of best-practice information that providers in the lung cancer space can give to patients and their caregivers at each point of interaction.

Objective

The objective of this scoping review was to investigate and analyze articles related to lung cancer patient and caregiver physical, psychological, social, and spiritual well-being to provide an evidence base for the development of an integrative digital education platform to empower patients and their caregivers following lung cancer diagnosis.

Methods

Search Strategy

Utilizing the Joanna Briggs scoping review method, a 3-step search strategy was undertaken: (1) an initial limited search of PubMed and MEDLINE; (2) an extensive search using all identified keywords and index terms across all included databases; and (3) a hand search of the reference lists of included articles. This review was limited to studies published in English from 2008 to 2018. Keywords used in the search are shown in Table 1.

The PRISMA model was applied to identify articles centered on the domains of well-being and assessed for relevance to the review using information provided in the title and abstract by 2 independent reviewers. If the reviewers had doubts about the relevance of a study from the abstract, the full-text article was retrieved. The full-text article was retrieved for all studies that met the inclusion criteria of the review. Two reviewers independently examined the full-text articles to determine whether they met inclusion criteria. Any disagreements that arose between reviewers were resolved through discussion.

Extraction of Results

From included articles, data were extracted using a charting instrument aligned with this research objective and question (Table 2). Study details and characteristics extracted included the following: authors, year of publication, study design, sample size and statistical methods, purpose/results/findings, limitations, and conclusions/recommendations/implications. The QOL component was also identified.

Results

After removing duplicates, 1610 articles were screened for inclusion. A total of 205 articles met the inclusion criteria based on titles and abstracts, and full-text publications were then reviewed. After review of full-text publications, 50 relevant articles were identified. Figure 1 shows the study selection process.

Research Design

A total of 36 studies used a qualitative design, 8 a quantitative design, and 6 used review or systematic review methodology. Table 3 shows the studies included in this scoping review by study design.

Year of Publication

Included studies were published between January 1, 2008, and November 26, 2018. Figure 2 shows studies categorized by QOL domain and publication year.

Contexts and Populations of Studies

The majority of the analyzed studies were implemented in oncology settings or from population-based samples. Overall, 25 of the 50 analyzed studies were implemented and evaluated exclusively in lung cancer patients, 10 in patients with lung and other cancer diagnoses, 6 in caregivers, and 9 in both patients and their caregivers.

Physical Well-being

We identified 26 articles evaluating the physical QOL component for patients with lung cancer and their caregivers.^21-46 Of these articles, 3 discussed physical health/function, 4 discussed self-care, 8 discussed treatment, and 1 discussed clinical trial enrollment.

General topics covered in articles related to treatment include information about different treatment options (eg, surgery, immunotherapy), factors affecting treatment selection (eg, clinical, biological, surgeon), and clinical trial participation.^{22,26,28,29,36,38,44,46} Other articles discussed symptom burden, interventions to support the toleration of treatment (eg, exercise, nutrition, rehabilitation), and the effects of symptoms on health-related QOL (HRQOL).^{21,24,27,34,35,37,39,40,42} Together, these articles highlight patients’ needs for education in these areas related to physical QOL, including treatment modalities, symptom burden and effects on HRQOL, and interventions to support treatment toleration.

Psychological Well-being

We identified 23 articles evaluating the psychological QOL component.^{23,25,30-33,41,43,45,47-60} Overall, 9 articles spanned the psychological and physical components, and 3 spanned the psychological and social components.

Several articles focused on general themes of the effects of palliative care, decision aids, supportive care, and multidisciplinary teams on social well-being, HRQOL, psychological distress, and health outcomes.^{30,32,49,51,54,57,59} Another group of articles focused on the effects of symptoms on psychological distress, fatigue, sleep disturbance, and emotional problems.^{23,25,31,33,43,45} Additional articles discussed patient and caregiver QOL, psychological distress, and emotional well-being.^{41,47,48,50,52,53,55,60} Finally, articles focused on distress prevalence and understanding of treatment goals.^56,58 Taken together, these articles demonstrate patients’ needs for support in areas related to the psychological QOL component, including the effects of different care models and symptoms on HRQOL, and effects of a diagnosis on both patients and caregivers in terms of QOL and emotional well-being.

Social Well-being

A total of 12 articles evaluated the social QOL component for patients with lung cancer and their caregivers.^{51,54,56,61-69} These articles evaluated support networks, employment, financial components, literacy components, socioeconomic status, and cultural components.

A common concern of “receiving confirmation as a person,” was identified by patients, centered around 4 major themes: (1) good relationships within a social network; (2) conversation enables support; (3) confidence in the situation; and (4) to manage by oneself.⁶⁸ The theme of confirmation through togetherness was also emphasized.⁶⁷ Other articles demonstrated the important relationship between health literacy and HRQOL,⁶² and the involvement of family members and the effects of cultural factors on treatment decisions.^63,65 Additional articles discussed financial toxicity, increased sick leave of spouses, and social stress levels, family functioning, and relationship quality reported by caregivers.^61,66,69 Finally, the substantial unmet needs of immigrants with lung cancer were noted.⁶⁴ These articles provide evidence for patients’ needs for education in these areas related to social QOL.

Spiritual Well-being

Only 1 article was identified that evaluated the spiritual QOL component.⁷⁰ Religiously affiliated patients reported better scores in the Faith subscale and items on finding strength and comfort in faith and spiritual beliefs compared with nonaffiliated patients. Nonaffiliated patients had better scores for feeling a sense of harmony within oneself. Patients who received the intervention had significantly better scores for the Meaning/Peace subscale. These results support the multidimensionality of spiritual well-being that includes meaning and faith for lung cancer patients and family caregivers regardless of religious affiliation.

Discussion

Limitations

It is well established that a diagnosis of lung or other cancer contributes to significant burden, particularly related to QOL, on both the patient and the caregiver.^7-9,71 However, in this scoping review, only 6 studies focused on effects in caregivers, whereas 9 studies focused on QOL effects on both patients and caregivers. The remaining studies focused on QOL effects in patients alone.

This scoping review revealed the lack of studies focusing on spiritual well-being, which limits the ability for inclusion in a patient education tool. Review articles focused on spirituality have highlighted associations between spirituality or religiosity and health that are potentially causal.^72,73 However, further studies are needed.

This scoping review was limited based on the inclusion of studies only published in English in the last decade. Articles published in other languages or studies published more than 10 years ago may have provided important information for this review.

Key Findings

Overall, our search strategy extracted a total of 1610 records, from which 205 full-text articles were evaluated, and a total of 50 relevant studies were included in this scoping review. The most commonly evaluated QOL components were physical and psychological well-being. We found 9 articles that spanned the psychological and physical components, and 3 that spanned the psychological and social components. The current literature does not provide sufficient information regarding spirituality, caregiver QOL, or the effectiveness of interventions targeting specific QOL components.

Implications for Practice

The findings from these studies will help facilitate the development of an integrative digital education platform to empower patients and their caregivers following lung cancer diagnosis. Upon completion, this education platform will be used to provide patients and their caregivers with information related to QOL components that can better prepare them and assist in the identification of interventions or tools to improve QOL throughout the disease process.

Conclusions

The results of this scoping review highlighted patients’ need for information regarding physical, social, and spiritual QOL components. These findings also demonstrate a continuing need for research evaluating these QOL components in caregivers of patients with lung cancer. Addressing these gaps will provide an evidence base for the development of an integrative digital education platform to empower patients and their caregivers following lung cancer diagnosis.

References

1. Sugimura H, Yang P. Long-term survivorship in lung cancer: a review. Chest. 2006;129:1088-1097.
2. Soni MK, Cella D, Masters GA, et al. The validity and clinical utility of symptom monitoring in advanced lung cancer: a literature review. Clin Lung Cancer. 2002;4:153-160.
3. Koczywas M, Cristea M, Thomas J, et al. Interdisciplinary palliative care intervention in metastatic non-small-cell lung cancer. Clin Lung Cancer. 2013;14:736-744.
4. Lehto RH. Identifying primary concerns in patients newly diagnosed with lung cancer. Oncol Nurs Forum. 2011;38:440-447.
5. Northouse L, Williams AL, Given B, McCorkle R. Psychosocial care for family caregivers of patients with cancer. J Clin Oncol. 2012;30:1227-1234.
6. Blum K, Sherman DW. Understanding the experience of caregivers: a focus on transitions. Semin Oncol Nurs. 2010;26:243-258.
7. Hudson P. Positive aspects and challenges associated with caring for a dying relative at home. Int J Palliat Nurs. 2004;10:58-65; discussion 65.
8. Proot IM, Abu-Saad HH, ter Meulen RH, et al. The needs of terminally ill patients at home: directing one’s life, health and things related to beloved others. Palliat Med. 2004;18:53-61.
9. Given B, Wyatt G, Given C, et al. Burden and depression among caregivers of patients with cancer at the end of life. Oncol Nurs Forum. 2004;31:1105-1117.
10. Hodges LJ, Humphris GM, Macfarlane G. A meta-analytic investigation of the relationship between the psychological distress of cancer patients and their carers. Soc Sci Med. 2005;60:1-12.
11. Palos GR, Mendoza TR, Liao KP, et al. Caregiver symptom burden: the risk of caring for an underserved patient with advanced cancer. Cancer. 2011;117:1070-1079.
12. Badr H, Taylor CL. Social constraints and spousal communication in lung cancer. Psychooncology. 2006;15:673-683.
13. Lim C, Tsao MS, Le LW, et al. Biomarker testing and time to treatment decision in patients with advanced nonsmall-cell lung cancer. Ann Oncol. 2015;26:1415-1421.
14. Bullard JT, Eberth JM, Arrington AK, et al. Timeliness of treatment initiation and associated survival following diagnosis of non-small-cell lung cancer in South Carolina. South Med J. 2017;110:107-113.
15. Labbe C, Anderson M, Simard S, et al. Wait times for diagnosis and treatment of lung cancer: a single-centre experience. Curr Oncol. 2017; 24:367-373.
16. Johansen NJ, Saunders CM. Value-based care in the worldwide battle against cancer. Cureus. 2017;9(2):e1039.
17. Hauser K, Koerfer A, Kuhr K, et al. Outcome-relevant effects of shared decision making. Dtsch Arztebl Int. 2015;112:665-671.
18. Joosten EA, DeFuentes-Merillas L, de Weert GH, et al. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom. 2008;77:219-226.
19. Zimmerman EB, Wolf SH, Haley A. Understanding the Relationship Between Education and Health: A Review of the Evidence and an Examination of Community Perspectives. Agency for Healthcare Research and Quality, Rockville, MD. www.ahrq.gov/professionals/education/curricu lumtools/population-health/zimmerman.html.
20. Suarez-Almazor ME, Richardson M, Kroll TL, Sharf BF. A qualitative analysis of decision-making for total knee replacement in patients with osteoarthritis. J Clin Rheumatol. 2010;16:158-163.
21. Bayly J, Edwards BM, Peat N, et al. Developing an integrated rehabilitation model for thoracic cancer services: views of patients, informal carers and clinicians. Pilot Feasibility Stud. 2018;4:160.
22. Billmeier SE, Ayanian JZ, Zaslavsky AM, et al. Predictors and outcomes of limited resection for early-stage non-small cell lung cancer. J Natl Cancer Inst. 2011;103:1621-1629.
23. Brant JM, Beck SL, Dudley WN, et al. Symptom trajectories during chemotherapy in outpatients with lung cancer, colorectal cancer, or lymphoma. Eur J Oncol Nurs. 2011;15:470-477.
24. Cardwell CR, Mc Menamin U, Hughes CM, Murray LJ. Statin use and survival from lung cancer: a population-based cohort study. Cancer Epidemiol Biomarkers Prev. 2015;24:833-841.
25. Choi SH, Chan RR, Lehto RH. Relationships between smoking status and psychological distress, optimism, and health environment perceptions at time of diagnosis of actual or suspected lung cancer. Cancer Nurs. 2019;42:156-163.
26. Cykert S, Dilworth-Anderson P, Monroe MH, et al. Factors associated with decisions to undergo surgery among patients with newly diagnosed early-stage lung cancer. JAMA. 2010;303:2368-2376.
27. Dreher M, Krüger S, Schulze-Olden S, et al. Sleep-disordered breathing in patients with newly diagnosed lung cancer. BMC Pulm Med. 2018;18:72.
28. Johnson M, Pennell NA, Borghaei H. “My patient was diagnosed with nontargetable advanced non-small cell lung cancer. What now?” Diagnosis and initial treatment options for newly diagnosed patients with advanced NSCLC. Am Soc Clin Oncol Educ Book. 2018;38:696-707.
29. Kehl KL, Arora NK, Schrag D, et al. Discussions about clinical trials among patients with newly diagnosed lung and colorectal cancer. J Natl Cancer Inst. 2014;106:dju216.
30. Kenzik KM, Ganz PA, Martin MY, et al. How much do cancer-related symptoms contribute to health-related quality of life in lung and colorectal cancer patients? A report from the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium. Cancer. 2015;121:2831-2839.
31. Kozachik SL, Bandeen-Roche K. Predictors of patterns of pain, fatigue, and insomnia during the first year after a cancer diagnosis in the elderly. Cancer Nurs. 2008;31:334-344.
32. McCorkle R, Jeon S, Ercolano E, et al. An advanced practice nurse coordinated multidisciplinary intervention for patients with late-stage cancer: a cluster randomized trial. J Palliat Med. 2015;18:962-969.
33. Morrison EJ, Novotny PJ, Sloan JA, et al. Emotional problems, quality of life, and symptom burden in patients with lung cancer. Clin Lung Cancer. 2017;18:497-503.
34. Murphy RA, Mourtzakis M, Chu QS, et al. Nutritional intervention with fish oil provides a benefit over standard of care for weight and skeletal muscle mass in patients with nonsmall cell lung cancer receiving chemotherapy. Cancer. 2011;117:1775-1782.
35. Reinke LF, Feemster LC, Backhus LM, et al. Assessment and management of symptoms for outpatients newly diagnosed with lung cancer. Am J Hosp Palliat Care. 2016;33:178-183.
36. Rolfo C, Caglevic C, Santarpia M, et al. Immunotherapy in NSCLC: a promising and revolutionary weapon. Adv Exp Med Biol. 2017;995:97-125.
37. Ruiz J, Miller AA, Tooze JA, et al. Frailty assessment predicts toxicity during first cycle chemotherapy for advanced lung cancer regardless of chronologic age. J Geriatr Oncol. 2019;10:48-54.
38. Santos FN, Cruz MR, Riera R. Chemotherapy for advanced non-small-cell lung cancer in elderly patients. JAMA Oncol. 2016;2:1645-1646.
39. Schulkes KJ, Hamaker ME, van den Bos F, van Elden LJ. Relevance of a geriatric assessment for elderly patients with lung cancer—a systematic review. Clin Lung Cancer. 2016;17:341-349.
40. Sebio Garcia R, Yanez Brage MI, Gimenez Moolhuyzen E, et al. Functional and postoperative outcomes after preoperative exercise training in patients with lung cancer: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg. 2016;23:486-497.
41. Shaffer KM, Jacobs JM, Nipp RD, et al. Mental and physical health correlates among family caregivers of patients with newly-diagnosed incurable cancer: a hierarchical linear regression analysis. Support Care Cancer. 2017;25:965-971.
42. Shallwani SM, Simmonds MJ, Kasymjanova G, Spahija J. Quality of life, symptom status and physical performance in patients with advanced non-small cell lung cancer undergoing chemotherapy: an exploratory analysis of secondary data. Lung Cancer. 2016;99:69-75.
43. Shin JA, Kosiba JD, Traeger L, et al. Dyspnea and panic among patients with newly diagnosed non-small cell lung cancer. J Pain Symptom Manage. 2014;48:465-470.
44. Tabchi S, Kassouf E, Florescu M, et al. Factors influencing treatment selection and survival in advanced lung cancer. Curr Oncol. 2017; 24:e115-e122.
45. Vos MS, Putter H, van Houwelingen HC, de Haes HC. Denial and physical outcomes in lung cancer patients, a longitudinal study. Lung Cancer. 2010;67:237-243.
46. Yoon SM, Shaikh T, Hallman M. Therapeutic management options for stage III non-small cell lung cancer. World J Clin Oncol. 2017;8:1-20.
47. El-Jawahri A, Greer JA, Pirl WF, et al. Effects of early integrated palliative care on caregivers of patients with lung and gastrointestinal cancer: a randomized clinical trial. Oncologist. 2017;22:1528-1534.
48. Grant M, Sun V, Fujinami R, et al. Family caregiver burden, skills preparedness, and quality of life in non-small cell lung cancer. Oncol Nurs Forum. 2013;40:337-346.
49. Greer JA, Jacobs JM, El-Jawahri A, et al. Role of patient coping strategies in understanding the effects of early palliative care on quality of life and mood. J Clin Oncol. 2018;36:53-60.
50. Jacobs JM, Shaffer KM, Nipp RD, et al. Distress is interdependent in patients and caregivers with newly diagnosed incurable cancers. Ann Behav Med. 2017;51:519-531.
51. Jones RA, Steeves R, Ropka ME, Hollen P. Capturing treatment decision making among patients with solid tumors and their caregivers. Oncol Nurs Forum. 2013;40:E24-E31.
52. Kim Y, van Ryn M, Jensen RE, et al. Effects of gender and depressive symptoms on quality of life among colorectal and lung cancer patients and their family caregivers. Psychooncology. 2015;24:95-105.
53. Kim JY, Sun V, Raz DJ, et al. The impact of lung cancer surgery on quality of life trajectories in patients and family caregivers. Lung Cancer. 2016;101:35-39.
54. Lorhan S, Dennis D, van der Westhuizen M, et al. The experience of people with lung cancer with a volunteer-based lay navigation intervention at an outpatient cancer center. Patient Educ Couns. 2014;96:237-248.
55. Milbury K, Mallaiah S, Lopez G, et al. Vivekananda yoga program for patients with advanced lung cancer and their family caregivers. Integr Cancer Ther. 2015;14:446-451.
56. Nehls W, Gabrijel S, Kiss A, et al. Physician communication in a lung cancer center—does the message come across? Pneumologie. 2013;67:688-693.
57. Nipp RD, Greer JA, El-Jawahri A, et al. Coping and prognostic awareness in patients with advanced cancer. J Clin Oncol. 2017;35:2551-2557.
58. Steinberg T, Roseman M, Kasymjanova G, et al. Prevalence of emotional distress in newly diagnosed lung cancer patients. Support Care Cancer. 2009;17:1493-1497.
59. Sun V, Grant M, Koczywas M, et al. Effectiveness of an interdisciplinary palliative care intervention for family caregivers in lung cancer. Cancer. 2015;121:3737-3745.
60. Tan JY, Molassiotis A, Lloyd-Williams M, Yorke J. Burden, emotional distress and quality of life among informal caregivers of lung cancer patients: an exploratory study. Eur J Cancer Care (Engl). https://doi.org/10.1111/ecc.12691. 2018.
61. Gilligan AM, Alberts DS, Roe DJ, Skrepnek GH. Death or debt? National estimates of financial toxicity in persons with newly-diagnosed cancer. Am J Med. 2018;131:1187-1199.
62. Halverson JL, Martinez-Donate AP, Palta M, et al. Health literacy and health-related quality of life among a population-based sample of cancer patients. J Health Commun. 2015;20:1320-1329.
63. Hobbs GS, Landrum MB, Arora NK, et al. The role of families in decisions regarding cancer treatments. Cancer. 2015;121:1079-1087.
64. John DA, Kawachi I, Lathan CS, Ayanian JZ. Disparities in perceived unmet need for supportive services among patients with lung cancer in the Cancer Care Outcomes Research and Surveillance Consortium. Cancer. 2014;120:3178-3191.
65. Lin JJ, Mhango G, Wall MM, et al. Cultural factors associated with racial disparities in lung cancer care. Ann Am Thorac Soc. 2014;11:489-495.
66. Litzelman K, Kent EE, Rowland JH. Social factors in informal cancer caregivers: the interrelationships among social stressors, relationship quality, and family functioning in the CanCORS data set. Cancer. 2016;122:278-286.
67. Sjolander C, Ahlstrom G. The meaning and validation of social support networks for close family of persons with advanced cancer. BMC Nurs. 2012;11:17.
68. Sjölander C, Berterö C. The significance of social support and social networks among newly diagnosed lung cancer patients in Sweden. Nurs Health Sci. 2008;10:182-187.
69. Sjövall K, Attner B, Lithman T, et al. Sick leave of spouses to cancer patients before and after diagnosis. Acta Oncol. 2010;49:467-473.
70. Sun V, Kim JY, Irish TL, et al. Palliative care and spiritual well-being in lung cancer patients and family caregivers. Psychooncology. 2016;25:1448-1455.
71. Clark MM, Rummans TA, Atherton PJ, et al. Randomized controlled trial of maintaining quality of life during radiotherapy for advanced cancer. Cancer. 2013;119:880-887.
72. Levin JS. Religion and health: is there an association, is it valid, and is it causal? Soc Sci Med. 1994;38:1475-1482.
73. Panzini RG, Mosqueiro BP, Zimpel RR, et al. Quality-of-life and spirituality. Int Rev Psychiatry. 2017;29:263-282.