Religiosity and Spirituality in Military Veteran Cancer Survivors: A Qualitative Perspective

Abstract

Religiosity/spirituality (R/S) is often involved in coping with cancer. Qualitative research effectively captures the individuality of R/S constructs. Fourteen military veteran cancer survivors participated in focus groups. R/S questions included “How have your religious/spiritual beliefs affected how you cope with your cancer” and “How have your religious/spiritual beliefs changed as a result of your experience with cancer?” Five primary themes emerged: impact of cancer on R/S, meaning-making, prayer, religious/spiritual role of others, and facing death. Consistency and individuality characterized the role of R/S in cancer survivorship across themes. Implications for future research are discussed.

Cancer survival rates in older adults have steadily improved since 1975 (National Cancer Institute, 2007). Although these improvements are unarguably beneficial, cancer survivorship can be challenging. A significant portion of older adult cancer survivors endorse psychological distress including fear of cancer recurrence, anxiety, symptoms of traumatic stress, and depression (Cordova, Studts, Hann, Jacobsen, & Andrykowski, 2000; Deimling, Bowman, Sterns, Wagner, & Kahana, 2006; Kangas, Henry, & Bryant, 2002). Identifying the ways in which older adults cope with the stress of cancer survivorship will improve our understanding of their experience and inform interventions to reduce their distress.

Religious activities are commonly cited as strategies for coping with cancer (Cigrang, Hryshko-Mullen, & Peterson, 2003; Hamilton, Crandell, Kameron Carter, & Lynn, 2010; Ross, Hall, Fairley, Taylor, & Howard, 2008; Vachon, 2008; Zaza, Sellick, & Hillier, 2005). For example, 68.5% of a nationally representative sample of patients with a history of cancer reported praying for their health (Ross et al., 2008). In a study of patients with cancer, chronic pain, and cardiovascular disease, 26.1% of the sample spontaneously identified religious activities when asked how they coped with illness. Cancer patients in the study reported the highest relative percentage of religious coping responses compared to other patient groups (Cigrang et al., 2003).

However, the relationship between religious coping and psychological distress in the context of cancer is mixed. For example, religiosity/spirituality (R/S) has been associated with better health-related quality of life (Canada, Murphy, Fitchett, Peterman, & Schover, 2008; Edmondson, Park, Blank, Fenster, & Mills, 2008; Wildes, Miller, de Majors, & Ramirez, 2009) and general mental health (Purnell, Andersen, & Wilmot, 2009), and lower levels of depression (Canada et al., 2008; Hamilton, Crandell, et al., 2010) and traumatic stress in cancer survivors (Purnell et al., 2009). Similarly, reliance on a benevolent relationship with God is associated with better emotional and interpersonal functioning (Agarwal, Hamilton, Crandell, Moore, 2010; Gall, 2004). In addition, enhanced R/S is a common component of post-traumatic growth, or positive benefits of difficult life challenges, in people with cancer (Stanton, Bower, & Low, 2006).

On the other hand, religious coping strategies such as turning to God for support and feeling God’s presence have been associated with greater anxiety and transplant concerns in multiple myeloma patients and more physical symptoms in patients with advanced cancer (Sherman, Plante, Simonton, Latif, & Anaissie, 2009; Tarakeshwar et al., 2006). Negative religious coping, characterized by religious strain and conflict (e.g., questioning God’s love for me), has been consistently associated with higher levels of depression (Hebert, Zdaniuk, Schulz, & Scheier, 2009; Sherman et al., 2009) and anxiety (Sherman et al., 2009), lower levels of life satisfaction and quality of life (Hebert et al., 2009; Manning-Walsh, 2005; Tarakeshwar et al., 2006), and poor mental and physical health in people with cancer (Sherman, Simonton, Latif, Spohn, & Tricot, 2005).

This body of quantitative research suggests that the role of R/S in coping with cancer and survivorship is complex. However, quantitative research on this topic is limited by the measures available to assess R/S constructs. A recent review of measures of spirituality suggested that “the growing number of people who consider themselves spiritual but not religious may be uncomfortable and/or obtain lower scores on measures inclusive of religious language” (Kapuscinksi & Masters, 2010, p. 195). Qualitative research addresses these issues by offering an in-depth and individualized focus. In fact, qualitative designs have been recommended as a method for clarifying participants’ understanding of R/S constructs (Kapuscinksi & Masters, 2010).

Consistent with the quantitative research cited above, qualitative studies also suggest that R/S is involved in coping with cancer (Ardelt, Ai, & Eichenberger, 2008; Gall & Cornblat, 2002). Prayer is the most frequently cited religious behavior with participants praying for their family, positive treatment outcomes, amelioration of fear, healing, and comfort. Cancer survivors also report praising and thanking God in prayer (Campesino, 2009; Gall & Cornblat, 2002; Hamilton, Moore, Powe, Agarwal, & Martin, 2010; Levine, Aviv, Yoo, Ewing, & Au, 2009). However, God does not merely hear prayers. African American cancer survivors stated that God provided them with support and healing and lifted their spirits (Hamilton, Moore, et al., 2010; Holt et al., 2009). In a sample of middle-aged cancer survivors, participants reported giving God control over uncontrollable aspects of their disease, which strengthened participants’ spirituality (Ardelt et al., 2008).

R/S beliefs and behaviors are often described in qualitative research as helpful and beneficial in the context of cancer. For example, cancer survivors reported receiving support from church members (Gall & Cornblat, 2002; Hamilton, Moore, et al., 2010) and emotional healing from their R/S beliefs (Ardelt et al., 2008). R/S is also involved in making meaning of the cancer (Ardelt et al., 2008; Gall & Cornblat, 2002). In a study of breast cancer survivors, participants viewed the cancer as “part of God’s plan” (Gall & Cornblat, 2002, p. 529). Survivors of hematological malignancies described their cancer experience as a spiritual journey that happened for a particular reason and included a sense of being chosen, viewing cancer as a challenge, and taking responsibility for that challenge (McGrath, 2004). This journey led to increased confidence and assertiveness, greater compassion for others, increased closeness in familial relationships, and emphasis on living life to its fullest. Participants reported feeling fortunate to have undergone this journey due to these positive changes. In other studies, cancer allowed participants to deepen their relationship with God (Ardelt et al., 2008) and focus on positive aspects of life (Gall & Cornblat, 2002). Spiritual growth due to cancer was characterized by reprioritization and greater appreciation of important aspects of life, increased empathy for others, and reductions in self-centeredness (Ardelt et al., 2008; Foley et al., 2006).

However, qualitative studies also point to the challenges associated with R/S in the context of cancer. In a study of African American cancer survivors, some participants reported feeling abandoned by church members who did not provide support following a cancer diagnosis. Participants attributed this lack of support to others’ negative beliefs about and fears of cancer. Participants also reported hiding their cancer diagnosis from members of their congregation due to fear of stigma and pity (Hamilton, Moore, et al., 2010). In a sample of cancer patients receiving hospice care, 61% of participants reported experiencing spiritual pain at the time of the interview. The presence and intensity of spiritual pain were positively correlated with depression (Mako, Galek, & Poppito, 2006).

Qualitative research on R/S in the context of cancer offers an in-depth and personal view of participants’ experiences. However, this research is limited in notable ways. First, most studies with cancer patients focus on spirituality in palliative care and at the end of life. Second, many qualitative studies focus on breast cancer patients. Because different cancer diagnoses can require a range of treatments with highly variable impacts on health and quality of life, the role of R/S may vary across cancer types. Third, a significant proportion of qualitative studies on this topic focus on minority populations such as African Americans, Latino, and Korean participants.

One large but understudied population of cancer survivors is military veterans. In Fiscal Year 2007, more than 500,000 cancer survivors were treated within the Veteran’s Health Administration (VHA) (Moye, Schuster, Latini, & Naik, 2010). Overall, military veterans are considered at risk for hematologic, respiratory, and genitourinary cancers associated with military-related exposure to Agent Orange and other herbicides (U.S. Department of Veterans Affairs, 2010). In addition, the veteran population tends to be older and suffer higher rates of post-traumatic stress disorder (PTSD) than the general population (Moye et al., 2010), which may increase their risk for psychological distress following cancer. These characteristics make veteran cancer survivors a particularly important and relevant population in which to examine the role of R/S in cancer survivorship.

Based on previous research, the following research questions were addressed:

1. What is the impact of cancer on the religiosity/spirituality of veteran cancer survivors?

2. What is the role of religiosity/spirituality in coping with cancer for veteran cancer survivors?

METHOD

Participants and Procedures

Participants were initially recruited as part of a larger study investigating PTSD risk and resilience factors in veterans treated for cancer. Exclusion criteria included (1) diagnosis of dementia or an active psychotic disorder (per medical record review), (2) completion of cancer treatment more than 36 months ago, and (3) a primary diagnosis of basal cell carcinoma. Fourteen participants from the larger study attended a focus group and were compensated $30. Participants were selected based on nomination by a researcher from the larger study and participant availability. This study was approved by the Institutional Review Boards of the VA Boston Healthcare System and Harvard Medical School.

Focus Groups

Three 2-hour focus groups were conducted with four to six participants and two facilitators per group. The groups utilized a structured, goal-driven format and focused on four topic areas: PTSD/anxiety, posttraumatic growth, values/goals, and religious and spiritual issues (R/S). This article focuses on the content related to R/S.

Each focus group began with the question “how does having cancer affect you today?” Previously determined primary questions and probes were then posed for each topic area. The primary R/S questions included “how have your spiritual or religious beliefs affected how you cope with your cancer?” and “how have your spiritual or religious beliefs changed as a result of your experience with cancer?” The probe question stated “some people say they have found themselves questioning, challenging, or turning away from God or spiritual or religious beliefs as a result of their cancer, have you?” This question was posed if time allowed, and the content was not previously addressed by the group. The content of this question was addressed in all three focus groups; although the probe question was needed in only two of the three groups.

Coding

The focus groups were audio and video taped and the tapes were transcribed. Data coding and analysis were informed by a responsive interviewing model (Rubin & Rubin, 2005). Based on this model, data units or “blocks of information that are examined together” (Rubin & Rubin, 2005, p. 202) are extracted from the transcripts and combined based on the concept or theme they represent. In this study, all data units from the transcripts that referred to religiosity or spirituality were extracted from the transcripts. Data units were grouped into themes by the first author. The data units and themes were then provided separately to two other members of the research team who independently matched the data units to the themes. Percent agreement across the three raters was determined. Matches with low rater agreements were discussed and either reorganized or dropped from the analysis. Rater agreement for the final themes was then determined.

RESULTS

Participants ranged in age from 57 to 86 years (M = 66.2, SD = 9.2) and were 100% male. Of the sample, 42.9% (n = 6) reported being in a combat area during their military service. The sample was primarily White (92.9%, n = 13) with 7.1% (n = 1) African American. Participants endorsed relatively high levels of education, with 78.6% (n = 11) of the sample reporting at least some college education, while 14.3% (n = 2) of the sample graduated from high school and 7.1% (n = 1) endorsed some high school education. Regarding religious affiliation, the sample was primarily Christian (71.4%) with 57.1% (n = 8) identifying as Catholic and 14.3% (n = 2) identifying as Protestant. In addition, 14.3% (n = 2) identified as Jewish, 7.1% (n = 1) endorsed “other,” and 7.1% (n = 1) endorsed “none.”

Participants were an average of 13.7 months (range = 0–36 months) postcancer treatment. Cancer diagnosis varied across participants and included genitourinary (n = 4), digestive (n = 5), blood (n = 4), and other (n = 1) cancers. At diagnosis, 28.6% of participants had Stage 1 cancer (n = 4), according to the criteria of the American Joint Committee on Cancer. 35.7% (n = 5) were diagnosed with Stage 2 cancer, and 7.1% (n = 1) with Stage 4 cancer. Stage information was unavailable for 28.6% (n = 4) of the sample. Cancer treatments included surgery (n = 8; 57.1%), radiation (n = 4; 28.6%), and chemotherapy (n = 6; 42.9%). Four of these participants had two or more types of treatment. The majority of participants described their cancer as cured (42.9%, n = 6) whereas 21.4% (n = 3) reported being in remission, 21.4% (n = 3) described the cancer as active, and 14.3% (n = 2) reported being uncertain of their prognosis.

Eighty-eight total data units related to R/S were pulled from the transcripts. Participants spontaneously mentioned 29.5% of these data units, meaning that they were not direct responses to the R/S questions. Five primary themes were identified. Three independent raters matched the data units to the themes. All three raters agreed on the categorization of 57 (65%) of the data units. Two raters agreed on the categorization of 27 (31%) of the data units. No agreement in independent ratings occurred for 4 (5%) of the data units which were dropped from additional analyses. The five primary themes included impact of cancer on R/S, meaning making, prayer, religious/spiritual role of others, and facing death.

Impact of Cancer on R/S

Cancer affected participants’ R/S in various ways. The most common response was that cancer strengthened participants’ R/S beliefs. This type of response was often direct and explicit. For example, one participant stated, “I’m probably more spiritual. I mean, I think I would be lying if I said that I wasn’t.” Another participant stated “I’m more into my religion now, hoping maybe something, someone up above can help a little bit more.” For the most part, participants stated that cancer strengthened their longstanding beliefs, rather than creating new beliefs:

It (cancer) reinforced my faith is what it did. I didn’t have any fear when I got it, and I understand why I didn’t have any fear. I believe there’s a higher power out there for me, and it reinforced it.

In addition to strengthening their R/S, participants also reported engaging in more frequent religious behaviors as a result of their cancer. For example, “just that borderline between life and death started me talking to God a lot, the God that I talk to, anyway. It’s just enhanced it. It’s enhanced my beliefs and spirituality.”

However, not all participants reported an enhancement of their R/S due to cancer. Some participants stated that their cancer did not affect their R/S. “Spiritually, I don’t think I’m that much different than I was before, I mean spiritually, I’m still the same person … I’m still pretty much who I was before the cancer.” Another participant stated “If you believe in God, he’s suppose to, he’s suppose to have everything planned out anyway … so all your planning doesn’t mean a thing. So I really have no changes as far as I can see.” One participant recognized that various phases of cancer can differentially affect R/S but maintained that his R/S was not changed, stating:

I was never that strong in my religion. And so with the cancer, maybe if I was dying I would say a prayer or something like that, and have the rabbi come in and so on, but that’s the extent of it.

Although a relatively infrequent response, a few participants also described a decline in their R/S as a result of cancer. Most illustrative of this perspective is the participant who stated, “I’m probably less spiritual than I was before only because I am just fed up with everything, all the religions as they are. And I don’t think any of them are quite right, but I’m still searching.”

Meaning Making

Meaning making was conceptualized as the process of understanding a stressor by creating accounts, stories, or interpretations of significant life events. God’s role in the cancer was one way participants made meaning of their cancer. In this study, God played a role in many phases of participants’ cancer experience including diagnosis, treatment, and survivorship. Regarding diagnosis, participants consistently stated that God did not send or cause the cancer. One participant stated, “I don’t think God had a hand in any of this. I think it’s an illness, ya know? Not a plague from God.” In another case:

I’m sure there’s some people that say “oh why me? God why’d you do this to me?” – I don’t think he did it. I don’t know who did – I’d like to find this guy. But I don’t think it had anything to do with religion.

Another participant voiced a similar belief but offered an alternative explanation based on a conversation with his neighbor and fellow cancer survivor:

And she said, “this could all be from God” and I said, “God did this to me? I doubt it. The devil could’ve done it. I don’t think God did it.” And then she looked at me straight and she said, “God could be testing you.” I said, “well, you better direct light to him and tell him to knock it off because I’m tired of it” and that ended that in a heartbeat.

Although all three participants clearly state that God did not cause their cancer, the third participant suggests that the devil may have caused it.

Participants also discussed God’s role in the treatment of their cancer. For most participants, God played an active role and guided them and their providers throughout the treatment process. One participant stated that God led him to an expert surgeon and then guided the hand of the surgeon through a successful surgery. Another participant believed that God intervened directly stating:

it was the hand of God that prevented me from making that phone call and cancelling that test. All I can say is if I hadn’t taken the test, as sure as I’m sitting here, I’m a dead man. … I’ve had enough experiences since then, that in my mind it was the hand of God.

Although most participants felt that God influenced their treatment, a minority of participants felt that God could not affect their cancer treatment. For example, one participant stated:

I had the same girl tell me to go up and talk to father so and so (a priest). And I said, “what’s he going to do? Can he help the cancer? Can he cure me?” And she kinda gets upset a little bit but I’m not trying to be smart about it, I’m trying to ask why you think it helps.

Another participant believed that God did not directly influence treatment but provided him with strength to endure the process. “God ain’t gonna cure you today or tomorrow or next week. You need to just … that one day at a time. And just go through it, do the best you can do and I realize that God has given me everything that I need.”

Finally, participants described God’s role in their survival as active and helpful:

If I have anything to think about God, I think that he kinda likes me a lot as he gave me a pretty good break … because he’s done quite a bit in my life so I don’t know if you count that as spiritual or religious but he gave me a break.

Another participant described a reason God saved his life and how this affected his actions. “I believe the guy upstairs wants me around longer. There must be a reason why the guy upstairs wanted me around, to have two children. I see my children a lot more now.” Regarding this idea of “extra time,” another participant described a change in his view of time stating: “To me, it’s God’s time. I use that a lot in traffic, ya know, if somebody cuts me off, instead of chasing them or flipping them the bird, I just … [see it as God’s time].”

Participants also made meaning of their cancer by viewing it as an accepted part of their life course: “It was meant to be. I sure wish I didn’t have it, but I got it, and I don’t ask God why me, and I don’t curse him like I used to.” For some participants, this acceptance developed over time as explained by the following two participants: “Ya know, it kind of started ‘why me God?’ and this and that and the other thing. Ya know, and settle down a bit and realize, well, why not you?”

sometimes I try to figure it (cancer) out. Not for too long, it’s like trying to figure out what God’s all about … I try to figure out that cancer … I thought “it doesn’t matter. It doesn’t matter why you got it.” It’s probably an accumulation of things I did: diet, smoking, drinking, whatever. It is the way that it is. So maybe God just gave it to me so I could enjoy more. And I thought: “nah, I don’t know about that.” But whatever it is I’m learning from it, and I think that’s the important thing … not to be stuck in it, in pain and misery.

Prayer

Prayer was the only R/S behavioral practice discussed by participants. The content of participants’ prayer included thanking God and asking God for help. This prayer content was often explicitly stated: “And ya know I just thank, I thank the Lord upstairs for the time he’s given me here; whatever it’s all about.” Prayer requests often included prolonged life or a cure for their disease. “When I wake up in the morning, I ask God to keep me awake.” Participants also reported praying for others: “I still speak to him, and have little conversations with him, and I pray to him that things go better for my family.” Finally, some participants reported that prayer helped them cope with their cancer. “Everything that had happened to me in my life up to that point helped me to cope; along with a lot of prayer.”

Religious/Spiritual Role of Others

R/S did not occur in isolation for participants. Participants reported receiving spiritual support from others. “I have a friend who’s very connected with angels. And when I was in surgery, she was in FL and she actually sent me a little stuffed angel.” However, R/S interactions with others were not always experienced by participants as positive and supportive. One participant described feeling pressured by others to adopt religious beliefs and behaviors that were inconsistent with his views:

I got a woman that hangs around my wife and she’s really religious and she’s a cancer survivor herself – 11 years – and she teaches Bible class, CCD to the kids, she’s really into this … she said to me, “do you read the Bible?” and I said, “no.” She said “why?” And I said “why should I?” I questioned her on that end of it. And she said, “it’s helped me a lot spiritually.” And I said, “OK, do you think positive about your cancer?” And she said “yes and no.” And I said “well, I do.”

Participants also discussed the impact of their cancer on others’ R/S, reporting that their cancer strengthened the R/S of others, in some cases, more than it affected their own R/S:

It was different religious groups that latched on to me and they were praying and as I got better and better and better and the doctors said this is unbelievable, they thought ‘our prayers were answered’ and I think it helped them.

Then my two doctors—a father and son team—they interpreted that their prayers were answered by the different Gods they were praying to. So I think that my cancer increased their spirituality more than it did mine.

Facing Death

A final theme regarding participants’ R/S views of death also emerged. Participants’ views of death were often related to seeing family in the afterlife:

I lay my head down at night like my mom taught me when I was little. I go through my ritual and thank him for everything, for all my aunts and uncles who are now gone, and that someday I will be with them again … there are some fabulous people … that touched my life that, I’m hoping that maybe I will see them again, whenever that day comes.

Another participant hoped for a peaceful death and, again, to see loved ones: “And that’s what I look forward to, a nice peaceful death, and the ride, and the white light, or whatever. I believe there is a reuniting with my family and my loved ones.” However, participants also experienced some worry about death:

I’m hoping that I’ll be ready for it! You know, I can say sitting here that when he wants me, he’s going to take me. That’s what I believe is going to happen, and I’m hoping that I can just live up to the task and face it at that moment versus the ‘oh please don’t take me’ type of thing! I don’t want to be a baby about it.

DISCUSSION

The current study used a qualitative focus group design to examine the impact of cancer on military veteran cancer survivors’ R/S and the role of R/S in coping with cancer. Overall, the results indicated that R/S plays a role in cancer survivorship but that the nature of this role varies in important ways. Five primary themes emerged: impact of cancer on R/S, meaning making, prayer, the religious/spiritual role of others, and facing death.

Focus Group Themes

R/S is typically conceptualized as an independent or predictor variable in qualitative and quantitative research. Researchers are less likely to consider change in R/S due to other constructs. In this study, participants readily discussed the impact of cancer on their R/S. Most participants indicated that their cancer experience enhanced or strengthened their R/S. Although in the minority, other participants reported that their R/S did not change as a result of cancer or that they became less religious or spiritual. These results indicate that R/S can change due to cancer. However, this change varies across individuals, suggesting that an accurate understanding of the impact of the cancer experience on R/S requires sensitive and individualized assessment.

R/S was involved in participants’ attempts to make meaning of their cancer experience. Meaning making is the process of understanding a stressor and resolving discrepancies between that understanding and global beliefs (Park, Edmondson, Fenster, & Blank, 2008). Meaning making has been described as the core component of spirituality (McGrath, 2005) and has been shown to mediate the relationship between measures of religiosity and psychological distress (Nelson et al., 2009). Meaning making as described by participants in this study focused primarily on God’s role in all aspects of the cancer experience. Interestingly, the degree to which participants described God’s role as active varied across phases of the cancer experience. Participants did not believe God actively caused the cancer but did report that God assisted in treatment and influenced their survival.

This variation in participants’ view of God’s role over the course of cancer may reflect their positive views of God and desire to conserve this God image. However, it is important to note that a minority of participants stated that God would not or could not play an active role in their cancer treatment, demonstrating again the individual variability of these constructs. Overall, the change in participants’ views of God’s role over the course of the cancer experience suggests that R/S beliefs may be dynamic and reflect the current situation. Longitudinal research that assesses participants’ R/S views over the course of cancer treatment and survivorship would provide insight into the nature of this change over time.

Consistent with previous research (Campesino, 2009; Gall & Cornblat, 2002), the most frequent religious behavior endorsed by participants was prayer. In addition, participants generally described prayer in positive terms. However, the content of participants’ prayers was diverse and included praying for others, asking God for support and healing, and thanking God. The prominence of prayer and its diverse content suggest ripe areas for future research, including the impact of prayer on cancer survivors and differential mental health outcomes based on prayer content (e.g., Ai, Tice, Huang, Rodgers, & Bolling, 2008; Whittington & Scher, 2010).

Participants’ discussions of R/S interpersonal interactions revealed unique and unanticipated results. First, when discussing the role of others in their cancer experience, participants provided examples of positive and negative interpersonal interactions. Negative interactions included feeling pressured by others to rely on R/S beliefs and practices to cope with their cancer. This result was generally unanticipated given research on the positive impact of interpersonal spiritual support in people with medical illness (Bowie, Sydnor, Granot, & Pargament, 2004; Cohen, Yoon, & Johnstone, 2009). However, cancer survivors have also reported feeling abandoned by church members following a cancer diagnosis (Hamilton, Moore, et al., 2010). Additional research is needed to clarify the type and context of R/S interpersonal interactions that are positive and negative for cancer survivors.

Second, participants described the impact of their cancer on others’ R/S. Participants who addressed this theme reported that their cancer strengthened the R/S of those around them. For some participants, this occurred in the absence of a change in their own R/S. Although these results were unanticipated, they reflect the multitude of ways R/S can manifest in individual experience. In addition, they demonstrate that R/S can have positive and negative effects on individuals. Future research should consider including focus groups of survivors’ family, friends, and other support persons to directly assess the impact of cancer on their R/S.

Finally, discussions of R/S included references to views of death for some participants, despite the absence of an explicit question on this topic. This theme is considered exploratory because it was not asked about explicitly and had relatively few data units. However, we include it due to its importance and the need for further empirical exploration. Most participants who mentioned death hoped for a peaceful death that would reunite them with loved ones. The spontaneous presence of this topic suggests that thoughts of death may be prevalent and strong in cancer survivors. In addition, it is likely that participants did not express the full range of their thoughts and feelings on this topic because it was not a planned topic for the focus groups. Future research should focus on views of death in cancer survivors from R/S and secular perspectives across the course of cancer survivorship.

R/S Coping

One of the primary focus group questions asked participants to comment on the role of R/S in their attempts to cope with cancer. Despite this explicit reference to coping, relatively few participants discussed how their R/S beliefs and/or practices helped them deal with cancer. Multiple factors may explain this unexpected finding. First, R/S may not have been part of the coping process for these participants. Although R/S appears to have played a role in the cancer experience, it may not have been explicitly utilized as a coping strategy or way of helping participants deal with cancer. Second, participants may have interpreted the question differently than intended by the researchers. For example, participants may have understood coping to mean “reactions to” cancer rather than “attempts to deal with” cancer. Finally, actively using R/S to cope with cancer survivorship may not be part of the worldview of this population. These individuals may not conceptualize or experience R/S coping as a process associated with particular outcomes, which is often the conceptualization of research on this topic.

These results offer guidance for the assessment of coping in cancer survivors. In the event that researchers and participants hold differing definitions of coping, future studies may benefit from avoiding the term coping or providing a definition of the term. In addition, evaluating survivors’ use of R/S to cope with cancer separately from the effectiveness of these strategies may provide more information on the process of religious coping in cancer survivorship. Similarly, measures that assess the importance of various religious coping strategies rather than frequency of use may capture a different and unique component of religious coping.

Limitations

Although generalizability is not an explicit goal of qualitative research, limitations of this study affect the generalizability and degree to which R/S constructs were comprehensively assessed. First, the sample consisted of older male veterans who were White, primarily Christian, well educated, and living in the metro Boston area. Second, the study was cross-sectional, precluding longitudinal investigation of these constructs. Third, the focus groups covered a range of topics rather than focusing on R/S constructs. As a result, comprehensive discussion and full assessment of R/S constructs was not possible. Additional interviews focused solely on R/S in cancer survivorship would allow for greater exploration of the role of R/S in cancer survivorship.

Implications for Future Research

The themes that emerged from these focus groups were largely consistent with other qualitative research on R/S in cancer survivors (Campesino, 2009; Gall & Cornblatt, 2002), despite significant differences in sample characteristics across studies. Most notably, the current sample consisted of older male military veterans with a range of cancer diagnoses whereas other studies have focused on women, breast cancer survivors, and minorities. This convergence of themes suggests topics for increased focus related to aspects of R/S that are relevant to cancer survivors. Notable areas for future research include the nature, role, and meaning of prayer; the role of God across phases of the cancer experience; the expression of R/S in interpersonal interactions; and thoughts about death.

The terms spirituality and religious beliefs were purposively not defined in this study, allowing participants to rely on their personal understanding of these constructs. The individual variability observed in this study supports this type of methodology. However, a limitation of this method is that participants’ definitions of these constructs remain unknown and cannot be incorporated into the interpretation of their comments. As stated above, the same issue emerges for coping more broadly. Future research should consider eliciting participants’ personal definitions of R/S constructs to provide a context in which to understand their responses.

Similarly, although a minority, some participants described negative aspects of R/S in this and other qualitative studies (Gall & Cornblatt, 2002; Hamilton, Moore, et al., 2010). Direct questions regarding the challenges associated with R/S for cancer survivors such as feelings of disappointment or anger at God, tense interpersonal interactions, and intrapsychic R/S struggles may provide more direct information on the frequency and nature of these negative aspects of R/S.

One finding that emerged across themes is that consistency and individuality characterize the role of R/S in cancer survivorship. For example, the majority of participants reported that their R/S was strengthened by their cancer experience. However, a notable minority of participants indicated that their R/S did not change or actually decreased in the context of cancer. Similarly, prayer was consistently cited as the most frequent religious behavior but prayer content varied. This variability supports the use of qualitative research designs to study R/S in cancer survivorship as quantitative measures may not capture the subtlety and individuality of R/S experiences. A recent critical review of measures of spirituality concluded that “the experience of spirituality is not easy to verbalize, and even more difficult to operationalize for empirical investigation” (Kapuscinksi & Masters, 2010, p. 201). The authors recommended qualitative methods for “informing the process of scale development, as well as on its own to capture data regarding the experience of spirituality” (p. 201).

As cancer treatments improve, the number of older adults who are cancer survivors is likely to increase. Cancer survivorship can be difficult and R/S provides both resources and obstacles to coping with survivorship challenges. This study sheds light on the role of R/S in the experience of cancer survivors and suggests important areas for additional investigation. Further clarification of R/S in cancer survivorship will improve our understanding of these constructs and inform interventions to promote adaptive coping in cancer survivors.