Correlation between spiritual well-being and quality of life among patients with advanced cancer receiving palliative care in a tertiary cancer centre in Northern Kerala, India: a cross-sectional study

Abstract

Objectives

Spiritual well-being (SpWB) is a critical yet often underexplored component of holistic care for patients with advanced cancer. This study aimed to assess the SpWB and quality of life (QOL) levels and examine their correlation among patients receiving palliative care at a tertiary cancer centre in Kerala, India.

Design

Institution-based cross-sectional observational study among patients with advanced cancer conducted between August 2023 and December 2024.

Setting

The outpatient department of a major tertiary-level, autonomous cancer centre under the Government of Kerala, India.

Participants

398 patients with advanced cancer aged 18 and above.

Measures

SpWB and QOL were measured using validated Malayalam versions of the Functional Assessment of Chronic Illness Therapy–Spiritual well-being Expanded Version and European Organisation for Research and Treatment of Cancer, Quality of Life Core 30 questionnaires, respectively. Data collection included patient self-reports or assistance by a medical social worker.

Results

The median (IQR) age of participants was 59 (51–65) years; most were married (94.5%) and from an upper-lower socioeconomic background (55%). Hinduism was the predominant religion (67.1%). Almost all patients (99%) were aware of their diagnosis, but only 62.3% knew their prognosis. The median (IQR) SpWB score was 67.5 (57–76), significantly higher in females (p=0.02). The median (IQR) QOL score was 50 (41.7–66.7). SpWB was positively correlated with QOL (r=0.766, p<0.01) and negatively correlated with symptoms like constipation, fatigue, nausea, pain, insomnia and appetite loss.

Conclusions

SpWB showed a strong positive correlation with QOL among patients with advanced cancer. Enhancing SpWB may play a pivotal role in improving overall QOL in palliative care settings.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• Validated Malayalam versions of Functional Assessment of Chronic Illness Therapy–Spiritual Well-Being Expanded Version and European Organisation for Research and Treatment of Cancer, Quality of Life Core 30 ensured cultural relevance and reliable measurement.

• Sample size was scientifically calculated based on pilot study correlation data.

• Real-world data from a tertiary cancer centre enhances applicability to similar settings.

• Cross-sectional design limits causal inference between spiritual well-being and quality of life.

• Exclusion of cognitively impaired and critically ill patients may reduce generalisability.

Background

Cancer is a life-altering diagnosis that deeply impacts all aspects of a person’s life, including their emotional, social and spiritual dimensions.¹ The primary aim of cancer treatment is to achieve a cure; however, in the vast majority of advanced-stage cancers, a cure is seldom possible. In such cases, the focus shifts towards prolonging life while maintaining a good quality of life (QOL).

QOL is defined by the WHO as ‘individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns’. It is a broad-ranging concept incorporating in a complex way the person’s physical health, psychological state, level of independence, social relationships, personal beliefs and their relationships to salient features of the environment.²

Palliative care focuses on improving the QOL for individuals facing serious illnesses, emphasising holistic support rather than curative treatments.³ Among the various dimensions of care, spiritual well-being (SpWB) has gained increasing attention as a vital component in enhancing the overall QOL for patients with terminal illnesses.³

SpWB extends beyond religious beliefs, encompassing a sense of meaning, purpose, connection and inner peace.⁴ For many patients with cancer, the existential questions and uncertainties that accompany their condition can lead to spiritual distress, affecting their emotional resilience and ability to cope with the disease.⁵ Addressing these spiritual needs, therefore, becomes an essential part of palliative care, offering comfort and fostering a sense of acceptance and hope in the face of adversity.⁶ However, due to time constraints and poor training in eliciting spiritual concerns, these go unrecognised.^{7 8}

Improved SpWB is correlated with better overall QOL, psychosocial functioning and decreased cancer-related anxiety and depression.9,12 Unmet spiritual needs are associated with diminished QOL, less hospice utilisation and higher healthcare costs in terminally ill cancer patients.^{13 14} There is a paucity of literature on SpWB among patients with cancer from India, with studies conducted on a limited number of patients.^{15 16} One Indian study showed maintaining hope positively contributes to the QOL of patients with cancer.¹⁷

This paper reports the level of SpWB, QOL and the potential associations between the two, in patients with advanced cancer receiving palliative care in a tertiary cancer centre in Kerala, a South Indian state.

Materials and methods

Study design and setting

An institution-based cross-sectional observational study was conducted from 24 August 2023 to 4 December 2024 at the outpatient department of a major tertiary-level, autonomous cancer centre under the Government of Kerala, India.

Study population

All eligible patients treated at Malabar Cancer Centre were considered. The inclusion criteria were: (1) diagnosis of advanced cancer (defined as metastatic disease, recurrence or progressive disease) and receiving palliative care, (2) 18 years and above and (3) able to read and comprehend the Malayalam language. Exclusion criteria were: (1) patients with cognitive dysfunction (psychiatric illnesses, neurological disorders) precluding administration of the tool and (2) patients deemed unwell as per the investigator’s clinical assessment, defined as instability in vital signs requiring hospitalisation and/or intensive care unit (ICU) care.

Data collection

Patients satisfying the inclusion criteria were enrolled in the study after obtaining informed consent.

Demographic details (age, gender, diagnosis, performance status, type of treatment received, socioeconomic status and time since completion of primary treatment) were extracted from their case records and recorded in the data collection sheet (online supplemental file 1). Other details like marital status, religion followed, family type, awareness about the diagnosis and prognosis were collected by direct interview of the patients and recorded in the data collection sheet. SpWB and QOL were assessed using self-administered questionnaires completed by the patients or with the assistance of the medical social worker if required.

Spiritual Well-being

SpWB was measured using the Malayalam translated Functional Assessment of Chronic Illness Therapy–Spiritual Well-being Expanded Version (FACIT-Sp-Ex). The translation and linguistic validation of this questionnaire into Malayalam has been described in a previous publication.¹⁸ FACIT-Sp-Ex builds on the original 12-item FACIT-Sp with 11 additional items that address the following aspects of SpWB: connectedness, love, gratitude and forgiveness grouped as the relational subscale.¹⁹ The FACIT-Sp-Ex questionnaire contains a total of 23 items with four subscales: (1) Meaning of life (sp2, sp3, sp5 and sp8), (2) Peace (sp1, sp4, sp6 and sp7), (3) Faith (sp9, sp10, sp11 and sp12) and (4) Relational subscale (sp13–sp23). Each item is assessed according to a 5-point Likert response scale from 0 to 4, with reverse scoring for Sp4 and Sp8. Subscale scores are calculated by first reversing negatively stated items (subtracting the response from ‘4’) and then summing the raw (0–4) scores. A total score is then derived by summing subscale scores. A higher score indicates better SpWB. The total score for SpWB ranges from 0 to 92, with subscale maximum scores of 16 for Meaning, 16 for Peace, 16 for Faith and 44 for the Relational domain. Cronbach’s alpha was calculated in this study to reconfirm the internal consistency.

Quality of life

QOL was measured using the Malayalam-validated version of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30).²⁰ Permission to use the translated version and its scoring manual was obtained from the EORTC QLQ Group. It is a 30-item instrument designed to measure QOL in all patients with cancer.^{21 22} The QLQ-C30 is composed of both multi-item scales and single-item measures. It is self-administered and includes: (1) five functional scales (physical, PF; role, RF; cognitive, CF; emotional, EF and social, SF); (2) three symptom scales (fatigue, FA; pain, PA and nausea and vomiting, NV;) (3) six single items (dyspnoea, appetite loss, sleep disturbance, constipation, diarrhoea and financial impact of the disease and treatment and (4) two items for global health status (GHS) or QOL scale. All items employ a 4-point Likert scale (1=‘not at all’ to 4=‘very much’), except for the two items in the global scale, which use a 7-point scoring scale (rated from 1=‘very poor’ to 7=‘excellent’). Raw scores were linearly transformed to a 0–100 scale following the official EORTC scoring manual. A high score for a functioning scale represents a healthy level of functioning, a high score for the GHS scale represents a high QOL, but a high score for a symptom scale/item represents a high level of symptomatology/problems.²³

Sample size calculation

Since there are no prior studies looking into the correlation between SpWB assessed by the FACIT–SP-Ex questionnaire and QOL assessed using the Malayalam version of EORTC QLQ-C30 in patients with cancer diagnosed with advanced cancer and receiving palliative care, the study sample size was computed using the results of Pearson correlation coefficient (r=0.14) obtained from a pilot study done between 22 October 2022 and 11 April 2023 on 10 patients using convenience sampling with the same eligibility criteria as mentioned above.

With a correlation coefficient r=0.140, using a two-tailed test, at 5% level of significance and 80% power, the minimum sample size was calculated to be 398.

Statistical analysis

Data were entered into Microsoft Excel and analysed using SPSS V.29. Sociodemographic and clinical profiles of the study participants are described in proportions. The mean (SD) or median (IQR) of continuous variables such as age and scores was calculated based on the distribution of data. Comparison between various categories of independent variables was done using the Mann-Whitney U test or the Kruskal-Wallis test. Significance values were adjusted by the Bonferroni correction for multiple tests.

To check the correlation between different scores, the Spearman correlation coefficient was computed.

Patient and public involvement

Patients or the public were not involved in the design, conduct, reporting or dissemination plans of our research.

Results

A total of 398 patients (199 females and 199 males) participated in the study. Median (IQR) age of the participants was 59 (51–65) years. The majority (94.5%) of the participants were married, and 55% belonged to the upper-lower socioeconomic status. More than half (67.1%) of the participants were followers of the Hindu religion. 64% of them lived in a nuclear family, and 55.5% of them were cared for primarily by their spouses. Among the patients studied, 23.8% (N=95) had breast cancer, followed by lung (21.9%) and gastrointestinal tract (21.6%) as their primary diagnosis. 75% were diagnosed as having de novo metastatic disease at the time of their participation in this study. 40% of the participants were on some form of active palliative anticancer treatment. The majority (99%) of the patients were aware of the cancer diagnosis, but only 62.3% were aware of the prognosis (online supplemental table 1).

The median (IQR) SpWB score assessed by the FACIT Sp-Ex version 4 tool was 67.50 (57–76). The median (IQR) score for the ‘Meaning’, ‘Faith’, ‘Peace’ and ‘Relational’ subscales was 11.00 (9–13), 12.00 (8–15), 9.00 (6–11) and 37.00 (32–40), respectively (online supplemental table 2). There was a significant difference in the SpWB between males and females (66.00 (56–75) vs 70.00 (58–78), p=0.02). The median SpWB score was higher in females compared with males.

There were significantly higher SpWB scores in Muslim patients compared with patients of other religions (online supplemental table 3). However, there was no significant difference in the SpWB between male and female Muslim patients (73 (62-77) vs 73 (60.50–79.25), p=0.40). The Peace subscale scores were significantly higher in unmarried patients and in patients belonging to the upper middle socioeconomic status. Patients who were not aware of their diagnosis scored higher on the Peace subscale, and those who were aware of their prognosis scored higher on the Meaning subscale. SpWB scores were not influenced significantly by family type, site of malignancy, treatment type, nature of the advanced disease, educational level of patients, performance status or whether patients were receiving any anticancer treatment at the time of recruitment into the study (online supplemental table 1). Cronbach’s alpha of FACIT-Sp-Ex was 0.86 in this study.

The median (IQR) QOL score was 50 (41.7–66.7). Females reported higher scores than males (58.3 vs 50, p=0.041). Functional scale scores ranged from 50 (33.3–66.7) for ‘Role functioning’ to 83.3 (66.7–100) for ‘Cognitive functioning’ and ‘Social functioning’. Symptom scales ranged from 0 for ‘Diarrhoea’ to 50 (33–83) for ‘Pain’ (table 1). Females reported better scores in ‘Role functioning’ (p<0.001) while males reported better scores in ‘Emotional functioning’ (p=0.011). Females also reported less ‘Constipation’ (p<0.001) while men reported less ‘Nausea/Vomiting’ (p=0.030) and lower levels of ‘Appetite loss’ (p=0.049). Cronbach’s alpha of EORTC QLQ C30 was 0.85 in this study.

Table 1. Association between gender and the median scores of the subscales of EORTC-C30 and FACIT Sp-Ex.

	Total n=398	Males n=199	Females n=199	P value
EORTC-QLQ-C30
Global health status/quality of life*	50 (41.7–66.7)	50 (41.7–58.3)	58.3 (41.7–66.7)	0.041
Functional scales*
Physical functioning	66.67 (40–80)	60 (40–80)	66.7 (46.7–80)	0.940
Role functioning	50 (33.3–66.7)	33.3 (33.3–66.7)	50 (33.3–83.3)	<0.001
Emotional functioning	75 (58.3–91.7)	83.3 (66.7–91.7)	75 (58.3–83.3)	0.011
Cognitive functioning	83.3 (66.7–100)	83.3 (66.7–100)	83.3 (66.7–100)	0.712
Social functioning	83.3 (66.7–100)	83.3 (50–100)	83.3 (66.7–100)	0.159
Symptom scales†
Fatigue	33 (22–44)	33 (22–44)	33 (22–44)	0.419
Nausea/vomiting	0 (0–33)	0 (0–17)	17 (0–33)	0.008
Pain	50 (33–83)	50 (33–67)	50 (33–83)	0.874
Dyspnoea	0 (0–33)	0 (0–33)	0 (0–33)	0.682
Insomnia	33 (0–67)	33 (0–67)	33 (0–67)	0.612
Loss of appetite	0 (0–33)	0 (0–33)	33 (0–33)	0.059
Constipation	0 (0–33)	0 (0–33)	0 (0–33)	<0.001
Diarrhoea	0 (0–0)	0 (0–0)	0 (0–0)	0.987
Financial difficulties	67 (33–100)	67 (33–100)	67 (33–100)	0.875
FACIT Sp Ex
Total	67.5 (57–76)	66 (56–75)	70 (58–78)	0.023
Meaning	11 (9–13)	11 (9–13)	11 (9–13)	0.169
Faith	12 (8–15)	11 (7–14)	13 (9–16)	<0.001
Peace	9 (6–11)	9 (6–11)	9 (6–12)	0.813
Relational	37 (32–40)	36 (32–40)	37 (33–40)	0.519

^*A high score for the global health status/quality of life and the functional scales represents a high quality of life and a high/healthy level of functioning.

^†A high score for the symptom scales represents a high level of symptomatology/problems.

EORTC-QLQ-C30, European Organisation for Research and Treatment of Cancer, Quality of Life Core 30; FACIT Sp-Ex, Functional Assessment of Chronic Illness Therapy - Spiritual well-being Expanded Version.

Correlations between FACIT Sp Ex and EORTC QLQ C30 domains

The FACIT Sp Ex SpWB score has a strong positive correlation with ‘GHS/QOL’(r=0.766, p<0.01), very weak positive correlation with ‘Physical functioning’ (r=0.199, p<0.01) and ‘Role functioning’(r=0.178, p<0.01) and weak positive correlation with ‘Emotional functioning’(r=0.265, p<0.01). The FACIT Sp Ex SWB score has a weak negative correlation with ‘Constipation’(r=−0.200, p<0.01) and ‘Insomnia’(r=–.202, p<0.01) and a very weak correlation with ‘Fatigue’(r=–0.159, p<0.01), ‘Nausea and Vomiting’(r=–0.103, p<0.05), ‘Pain’(r=–0.172, p<0.01), ‘Appetite loss’(r=–0.165, p<0.01) and ‘Financial difficulties’ (r=–0.154, p<0.01).

As shown in table 2, ‘Meaning’ has a moderate positive correlation with ‘GHS/QOL’ (r=0.479, p<0.01), weak positive correlation with ‘Physical functioning’ (r=0.270, p<0.01), ‘Role functioning’ (r=0.202, p<0.01) and ‘Emotional functioning’ (r=0.238, p<0.01) and a very weak positive correlation with ‘Social functioning’ (r=0.157, p<0.01) and ‘Cognitive functioning’ (r=0.132, p<0.01). ‘Meaning’ has a weak negative correlation with ‘Fatigue’ (r=–0.205, p<0.01) and ‘Appetite loss’ (r=–0.209, p<0.01) and a very weak negative correlation with ‘Nausea and Vomiting’ (r=–0.106, p<0.01), ‘Pain’ (r=–0.174, p<0.01), ‘Dyspnoea’ (r=–0.142, p<0.01), ‘Insomnia’ (r=–0.135, p<0.01) and ‘Constipation’ (r=–0.155, p<0.01).

Table 2. Spearman correlation of FACIT Sp-Ex score with EORTC QLQ C30 subscales (n=398).

	Meaning	Faith	Peace	Relational	FACIT Sp-Ex total
Global health status/quality of life	0.479*	0.618*	0.584*	0.628*	0.766*
Functional scales
Physical functioning	0.270†	0.061	0.165*	0.171*	0.199*
Role functioning	0.202*	0.118†	0.115†	0.144*	0.178*
Emotional functioning	0.238*	0.101†	0.327*	0.213*	0.265*
Cognitive functioning	0.132*	0.016	0.084	0.123†	0.101†
Social functioning	0.157*	0.113†	0.199*	0.180*	0.218*
Symptom scales
Fatigue	−0.205*	−0.079	−0.131*	−0.123†	−0.159*
Nausea/vomiting	−0.106†	−0.050	−0.065	−0.103†	−0.103†
Pain	−0.174*	−0.060	−0.167*	−0.149*	−0.172*
Dyspnoea	−0.142*	0.013	−0.031	−0.011	−0.043
Insomnia	−0.135*	−0.141*	−0.181*	−0.169*	−0.202*
Appetite loss	−0.209*	−0.117†	−0.134*	−0.110†	−0.165*
Constipation	−0.155*	−0.114†	−0.054	−0.234*	−0.200*
Diarrhoea	−0.037	0.036	0.012	−0.017	−0.012
Financial difficulties	−0.098	−0.057	−0.216*	−0.139†	−0.154*

^*Correlation is significant at the 0.01 level (two-tailed).

^†Correlation is significant at the 0.05 level (two-tailed).

EORTC QLQ C30, European Organisation for Research and Treatment of Cancer, Quality of Life Core 30; FACIT Sp-Ex, Functional Assessment of Chronic Illness Therapy Spiritual Wellbeing Expanded.

‘Faith’ has a strong positive correlation with ‘GHS/QOL’ (r=0.618, p<0.01), a very weak positive correlation with ‘Role functioning’ (r=0.118, p<0.05), ‘Emotional functioning’ (r=0.101, p<0.05) and ‘Social functioning’ (r=0.113, p<0.05). ‘Faith’ has a very weak negative correlation with ‘Insomnia’ (r=–0.141, p<0.01), ‘Appetite loss’ (r=–0.117, p<0.05) and ‘Constipation’ (r=–0.114, p<0.05).

‘Peace’ has a moderate positive correlation with ‘GHS/QOL’ (r=0.584, p<0.01), weak positive correlation with ‘Emotional functioning’ (r=0.327, p<0.01) and very weak positive correlation with ‘Physical functioning’ (r=0.165, p<0.01), ‘Role functioning’ (r=0.115, p<0.05) and ‘Social functioning’ (r=0.199, p<0.01 ‘Peace’ has a very weak negative correlation with ‘Fatigue’ (r=–0.131, p<0.01), ‘Pain’ (r=–0.167, p<0.01), ‘Insomnia’ (r=–0.181, p<0.01), ‘Appetite loss’ (r=–0.134, p<0.01) and ‘Financial difficulties’ (r=–0.216, p<0.01).

‘Relational’ subscale has a strong positive correlation with ‘GHS/QOL’ (r=0.628, p<0.01), very weak positive correlation with ‘Physical functioning’(r=0.171, p<0.01), ‘Role functioning’ (r=0.144, p<0.01), ‘Emotional functioning’ (r=0.213, p<0.01), ‘Cognitive functioning’ (r=0.123, p<0.05) and ‘Social functioning’ (r=0.180, p<0.01). ‘Relational’ subscale has a weak negative correlation with ‘Constipation’ (r=–0.234, p<0.01) and ‘Insomnia’ (r=–0.202, p<0.01) and a very weak negative correlation with ‘Fatigue’ (r=–0.159, p<0.01), ‘Nausea and Vomiting’ (r=–0.103, p<0.05) ‘Pain’ (r=–0.172, p<0.01) and ‘Financial difficulties’ (r=–0.154, p<0.01).

Discussion

Demographic dimensions

Our study revealed a relatively high level of SpWB among patients with advanced cancer, with a median (IQR) FACIT-Sp-Ex score of 67.5 (57–76). An Indian study of 100 adult patients with brain tumours using the same questionnaire revealed similar findings with a median (IQR) SpWB score of 64 (54–70).²⁴ This warrants further study, but factors such as effective coping mechanisms, spiritual beliefs or support systems that play a role in maintaining well-being despite the illness have been identified in other studies of Indian patients.^{24 25} Our findings are comparable to international data obtained using the same questionnaire. A study conducted among advanced cancer outpatients at MD Anderson Cancer Centre reported a median FACIT-Sp-Ex score of 68 in patients with spiritual pain and 81 in those without spiritual pain, indicating overall moderate-to-high levels of SpWB in this population.²⁶ The concordance between these international findings and our data suggests that patients with advanced malignancies, irrespective of geographic or cultural background, often maintain substantial levels of SpWB.

The SpWB scores were significantly higher in females compared with males with advanced cancer, especially in the Faith subscale, compared with the Meaning, Peace and Relational subscales. According to the Pew Research Centre’s analysis of censuses, surveys and population registers in 192 countries and territories, including India, an estimated 83.4% of women around the world identify with a faith group, compared with 79.9% of men.²⁷ Faith and SpWB were highly correlated, and given the higher identification with a faith group, this may contribute to the higher SWB in females. The cultural prominence of women’s religious participation in Kerala, exemplified by large women-led devotional events such as the Attukal Pongala, may contribute to women’s greater reliance on faith as a coping resource during serious illness.²⁸

Our study did not show any influence of educational status or marital status on the total SpWB score. However, the Peace subscale of the SpWB score showed a higher value in the unmarried patients compared with the married, divorced and patients who had lost their spouse.²⁹ This may be related to a sense of freedom from family responsibility. A small number of existing studies suggest unmarried individuals may derive a sense of internal peace through personal reflection, autonomy or spiritual coping mechanisms.³⁰ It is difficult to generalise this finding due to the limitations of the sample size in this study.

Interestingly, our study found that patients who were not aware of their diagnosis scored higher on the Peace subscale, while those who were aware of their prognosis scored higher on the Meaning subscale. This pattern may reflect that lack of awareness about the diagnosis reduces illness-related anxiety, allowing patients to maintain a greater sense of inner peace, whereas awareness of prognosis may prompt existential reflection, life review and engagement with meaning-making, enhancing the sense of purpose. Despite these subscale differences, the overall SpWB score did not differ significantly between the two groups, suggesting that gains in one dimension may be offset by lower scores in another. This highlights the multidimensional nature of SpWB, in which peace, meaning, faith and connection interact to shape overall spiritual health.

Religious dimensions

The SpWB in our study was significantly higher in Muslims compared with participants of other religious beliefs or atheists/agnostics. The differences were more apparent in the Faith subscale. There may be many factors to consider here. For example, in addition to Islamic beliefs and practices, the traditional Muslim family and communal approach may enhance SpWB by reducing isolation and reinforcing meaning and relationship.³¹ This difference between Muslims and other participants, therefore, warrants further study. However, there was no statistically significant gender variation in the SpWB in this community, probably due to the small sample size (21.4%).

Socioeconomic dimensions

This study did not show any influence of the socioeconomic status of the patients on their overall SpWB. However, upper middle socioeconomic status was associated with higher SpWB in the Peace subscale.

Symptoms

Our research found a statistically significant, strong positive correlation between SpWB (FACIT-Sp-Ex score) and QOL score, and a weak negative correlation between SpWB and symptom burden. These findings underscore the significance of SpWB as a central component of supportive care in advanced cancer.³² The Peace, Meaning, Faith and Relational subscales of FACIT Sp-Ex also showed a statistically significant, strong positive correlation with QOL. This was reported in other Indian studies and suggests the contribution of the domains of SpWB toward QOL appears to be very important and synergistic.^{33 34}

In addition, our study showed negative correlations between SpWB and symptoms, reinforcing the interconnection between physical health and SpWB shown elsewhere.³⁵ This inverse relationship between SWB and symptom burden suggests that when physical symptoms are inadequately managed, patients may experience greater spiritual distress.²⁶ This aligns with the total pain concept in palliative care, which recognises that suffering is multidimensional, encompassing physical, emotional, social and spiritual domains and supports the dictum of managing physical symptoms before, or at least alongside, addressing spiritual or existential pain.³⁶

The Biopsychosocial-Spiritual Model of Health recognises that spiritual health, along with biological, psychological and social factors, plays a significant role in a person’s well-being, healing and QOL.³⁷ Research suggests that spirituality reduces anxiety, depression and stress levels, thereby improving mental health outcomes.³⁸ An Indian study done among 103 cancer patients at a tertiary care institute found a statistically significant negative correlation between spirituality and depression (r=−0.209, p=0.05), suggesting that patients with higher spirituality experienced minimal or no depression.³⁹ Another cross-sectional study from India assessed 84 newly diagnosed cancer patients using the Hospital Anxiety and Depression Scale and the Spirituality Involvement and Belief Scale. The findings revealed a significant negative correlation between spirituality and psychological distress, indicating that higher spirituality was associated with lower levels of depression and anxiety. It was observed that there was a statistically significant negative correlation of spirituality with depression (Correlation coefficient r=–0.833, p=0.01) and anxiety (correlation coefficient r=−0.631, p=0.01).⁴⁰ Our study also showed a positive correlation between SpWB and ‘Emotional Functioning’ (r=0.265, p<0.01), indicating that patients who had high SpWB were more emotionally stable.

Our study found no significant association between overall SpWB and awareness of diagnosis, prognosis or performance status. Interestingly, the Peace subscale scores were higher in patients who were not aware of their disease, while the Meaning subscale scores were higher in those who were aware of their prognosis. These findings suggest that SpWB may be influenced more by internal, existential or relational dimensions than by external clinical factors. The lack of association with awareness of prognosis or diagnosis highlights the need for further research into how individuals make sense of their illness, find meaning in suffering and draw on spiritual or existential beliefs to cope despite declining physical function. This is consistent with prior studies showing that patients can maintain or even deepen their SpWB when facing poor prognoses or limited survival.^{26 41}

Limitations

This study has several limitations. The use of a convenience sample limits generalisability, and comparisons with other studies are constrained by variations in the instruments used to assess SpWB and QOL. The cross-sectional design also precludes causal inferences, and patients with higher SpWB may perceive or report symptoms differently. Moreover, spirituality is shaped by personal, cultural and religious factors that may not be fully captured through standardised tools. Some conceptual overlap exists between the FACIT-Sp Ex and EORTC QLQ-C30, particularly between the peace and relational domains and the emotional and social functioning scales, which could introduce partial redundancy. However, the FACIT-Sp Ex uniquely captures faith and existential meaning, suggesting that observed correlations reflect interconnected, not duplicate, dimensions of well-being.⁴² Future studies using longitudinal and mixed-method designs could clarify these relationships further.

Conclusions

The SpWB score was higher in our population of patients with advanced cancer compared with similar studies. The QOL of these patients is highly correlated with their SpWB. Hence, in patients with advanced cancer, meticulous attention directed at improving SWB is also essential to improve their overall QOL and vice versa.

Data availability statement

Data are available on reasonable request.