Abstract
Objective:
Many advanced cancer patients struggle with anxiety, depressive symptoms, and anger toward God and illness-related stressors. Patients may perceive their illness as an injustice (i.e., appraise their illness as unfair, severe, and irreparable or blame others for their illness), which may be a risk factor for poor psychological and spiritual outcomes. This study examined relations between cancer-related perceived injustice and psycho-spiritual outcomes as well as potential mediators of these relationships.
Methods:
Advanced lung (n=102) and prostate (n=99) cancer patients completed a one-time survey. Using path analyses, we examined a parallel mediation model including the direct effects of perceived injustice on psycho-spiritual outcomes (i.e., anxiety, depressive symptoms, anger about cancer, anger towards God) and the indirect effects of perceived injustice on psycho-spiritual outcomes through two parallel mediators: meaning making and acceptance of cancer. We then explored whether these relations differed by cancer type.
Results:
Path analyses indicated that perceived injustice was directly and indirectly – through acceptance of cancer but not meaning making – associated with psycho-spiritual outcomes. Results did not differ between lung and prostate cancer patients.
Conclusions:
Advanced cancer patients with greater perceived injustice are at higher risk for poor psycho-spiritual outcomes. Acceptance of cancer, but not meaning making, explained relationships between cancer-related perceived injustice and psycho-spiritual outcomes. Findings support testing acceptance-based interventions to address perceived injustice in advanced cancer patients.
Keywords: acceptance, advanced cancer, anger toward God, anxiety, depressive symptoms, meaning making, oncology, perceived injustice, psycho-oncology, spirituality
Background
Lung and prostate cancers are among the most common cancers worldwide.1 At advanced stages of these cancers, many patients experience anxiety, depressive symptoms, anger about cancer, and anger toward God for allowing the disease to occur.2-5 These psycho-spiritual outcomes have been associated with worse quality of life and non-adherence to cancer treatment.4-6 Underlying poor psycho-spiritual outcomes may be a sense of injustice.
Perceived injustice refers to cognitive appraisals reflecting the severity and irreparability of the circumstance, allocation of blame, and a sense of unfairness.7-9 According to Just World Theory, individuals have a need to believe that the world is just, allowing them to view their environment as predictable, stable, ordered, and meaningful.7-9 However, this sense of stability and order is disrupted when personal suffering is perceived as unnecessary and undeserved, resulting in a sense of injustice.7-9 Perceived injustice differs from related constructs of embitterment and demoralization. Embitterment refers to feelings of being wronged or mistreated in response to negative circumstances and includes specific cognitive, affective, and behavioral manifestations such as bitterness, destructive rage, and seeking revenge.10 Demoralization refers to a persistent sense of failure to meet one’s own or others’ expectations or being unable to cope with stressful life events.10 Demoralization also involves feelings of helplessness, hopelessness, meaninglessness, and/or existential distress.10
Given the numerous stressors associated with cancer,1-5 it can be perceived as an injustice, evoking a range of cognitive and affective responses. Patients may perceive themselves as “victims,” believing that they did not deserve this illness and perhaps that they cannot control the course of the illness. For advanced lung cancer patients, their short life expectancy, disabling symptoms (e.g., fatigue, breathlessness, pain), and smoking-related stigma1, 11 may heighten their perceived injustice. Indeed, many lung cancer patients report feeling stigmatized and blamed for their illness,11 but up to 26% of current/former smokers and 73% of never smokers do not hold themselves responsible.11, 12 For advanced prostate cancer patients, masculinity-related losses (e.g., decreased sense of self-reliance, sexual performance, incontinence) and the stigma related to these losses may heighten their perceived injustice.13 Furthermore, given the array of treatment options at earlier stages of prostate cancer, patients may end up regretting their treatment choices and blaming themselves or others for the subsequent results, including disease progression and long-term side effects.14
To date, most studies of perceived injustice in a medical context have focused on chronic pain. Two studies of breast cancer patients found that greater pain-related perceived injustice was associated with greater pain catastrophizing (i.e., assuming the worst possible outcome)15, 16 and worse quality of life.16 Other studies in chronic pain found that greater pain-related perceived injustice was associated with lower pain acceptance, which, in turn, was associated with worse pain intensity, functional impairment, and psychological outcomes such as anger, depressive symptoms, and anxiety.17, 18
Perceived injustice may impact psycho-spiritual outcomes through the mechanism of meaning making. This conceptualization is grounded in Just World Theory7-9 and Park’s Meaning Making Model.19 According to Park’s model, people search for meaning in stressful circumstances such as cancer.19 While meaning-making has been operationalized in a variety of ways, for the purposes of this study, meaning-making was defined as cognitive and emotional efforts to reduce the discrepancies between global (e.g., general beliefs about the world and self, goals, and a subjective sense of meaning) and situational meanings (e.g., appraisals of a specific situation). During times of stress, individuals make judgments about their situation (i.e., situational meanings), which may conflict with their global meanings.19 For example, perceiving a cancer diagnosis as unjust is a situational meaning that may differ from a patient’s global meanings (e.g., “the world is a just place”). When individuals identify discrepancies between situational and global meanings, they may experience distress and/or engage in meaning making to reduce these discrepancies.19 The process of meaning making may include positive reappraisals of the situation, goal revision, problem-solving strategies, or using a religious or spiritual framework to make sense of the situation.19 Meaning making is often operationalized as positive reappraisal, which can be measured with the COPE positive reinterpretation subscale.19, 20 In a cancer context, patients who cope with perceptions of injustice by positively reappraising their illness (e.g., believing that they have become stronger), may experience better psycho-spiritual outcomes.
Acceptance is another potential mechanism by which perceived injustice may impact psycho-spiritual outcomes. Acceptance refers to coming to terms with the situation or achieving a sense of peace19 and thus can be conceptualized as an active coping process.21, 22 Indeed, we conceptualized acceptance in a cancer context as “an active willingness to be present with cancer-related realities while giving up efforts to judge or control cancer-related appraisals or feelings.”22(p. 29) Acceptance of cancer may involve being aware of one’s disease stage and prognosis and facilitate medical decision-making. However, even when patients are not fully aware of their prognosis, they may accept the circumstances of which they are aware (such as a cancer diagnosis) and take action steps based on their level of awareness and personal values.23
When cancer is perceived as an injustice, patients may struggle to find meaning in their experience and accept their situation, resulting in poor psycho-spiritual outcomes. Although research has not examined these proposed relations in cancer patients, reduced pain acceptance has mediated the positive relationships between perceived injustice and psychological outcomes (e.g., anger, depressive symptoms) in patients with chronic pain.17, 24
The present study tested a model of the relationships between perceived injustice and psycho-spiritual outcomes in advanced lung and prostate cancer patients. We focused on these patient groups because of the high prevalence of these cancers and associated poor psycho-spiritual outcomes.1-5 We examined meaning making and acceptance as two potential mediators of the relations between perceived injustice and psycho-spiritual outcomes. We hypothesized that greater perceived injustice would be related to poorer psycho-spiritual outcomes through lower meaning making and acceptance. We also explored potential differences in the relationships among these variables by cancer type.
Methods
Participants and procedures
This cross-sectional survey study was approved by the Indiana University (IU) Institutional Review Board (IRB#: 1901972719). Participants were recruited from the IU Health cancer registry and IU Health University Hospital between March and August 2019. Patients were identified through medical record review and confirmation with attending oncologists. Eligible patients were: (1) ≥3 weeks post-diagnosis of inoperable stage IIIB, IIIC, or IV non-small cell lung cancer, extensive stage small cell lung cancer, or stage IV prostate cancer; (2) ≥18 years old; (3) English-speaking; and (4) not exhibiting significant cognitive impairment (<3 errors on a 6-item cognitive screener).25
Potentially eligible patients were mailed a study brochure, consent form, and an introductory letter with contact information for opting out of further contact. Research assistants called patients who did not opt out to describe the study, administer the cognitive screener, and obtain verbal informed consent. Consenting patients received electronic or paper copies of the survey based on their preference. Reminder calls or emails encouraged survey completion. Patients received a $25 gift card for their participation.
Measures
Demographic and medical factors
Most demographics were self-reported. Age, gender, and cancer-related information was obtained from medical records. Patients reported their functional status (i.e., Eastern Cooperative Oncology Group [ECOG] score)26 and completed a checklist of eight common medical comorbidities (e.g., arthritis, hypertension).27 Prognostic awareness was assessed with a self-report item on terminal illness acknowledgement.28
Religiosity was assessed with the 5-item Duke University Religion Index.29 This measure assesses engagement in organizational religious activities, non-organizational religious activities, and intrinsic religiosity. Items (e.g., “How often do you attend church or other religious meetings?”) were rated on 5- or 6-point scales, with higher scores indicating greater religiosity. This measure has evidence of good reliability and validity in cancer populations.29
Main study variables
Perceived injustice was measured using the 12-item Injustice Experience Questionnaire.7 Items (e.g., “It all seems so unfair”) were rated on a 5-point scale (0=Never to 4=All the time), with higher scores indicating greater perceived injustice.7 The phrase “when you think about your cancer” was added to the instructions to focus on cancer-related perceived injustice. This measure has strong evidence of reliability and validity in chronic pain populations.7
Meaning making was assessed with the 4-item Positive Reinterpretation subscale of the COPE measure.21 Items (e.g., “I try to grow as a person as a result of the experience”) were rated on a 4-point scale (1=I usually don’t do this at all to 4=I usually do this a lot), with higher scores indicating greater meaning making.21 This measure has strong evidence of reliability and validity in cancer populations.21
Acceptance of cancer was assessed with the 5-item Peaceful Acceptance subscale of the PEACE measure. Items (e.g., “To what extent are you able to accept your diagnosis of cancer?”) were rated on a 4-point Likert scale (1=Not at all to 4=To a large extent), with higher scores indicating greater acceptance.30 This measure demonstrated good reliability and validity in cancer populations.30
Depressive symptoms and anxiety were evaluated with the 4-item Patient-Reported Outcomes Measurement Information System (PROMIS) Depression (e.g., “In the past 7 days, I felt depressed”) and Anxiety measures (e.g., “In the past 7 days, I felt fearful”).31 Anger about cancer was assessed with the 5-item PROMIS Anger measure (e.g., “In the past 7 days, I felt angry”).31 The phrase “when I thought about my cancer” was added to the instructions to refer to anger about cancer. All PROMIS items were rated on a 5-point scale (1=Never to 5=Always), with higher scores indicating higher levels of the symptom. For anxiety and depressive symptoms, US general population-anchored T-scores were computed (Mean=50, SD=10). For anger about cancer, T-scores were not computed because of the change in instructions. PROMIS measures have demonstrated strong reliability and validity in cancer populations.31
Anger toward God was measured using the 4-item Anger/Disappointment subscale of the Attitudes Toward God Scale.32 Items (e.g., “To what extent do you currently feel angry at God?”) were rated on an 11-point scale (0=Not at all to 10=Extremely), with higher scores indicating greater anger toward God.32 This measure demonstrated good reliability and validity in cancer populations.32
Statistical analyses
Preliminary analyses (i.e., descriptive statistics, examination of normality, outliers, and missingness) were conducted in SPSS v.25.0. Then path analyses were conducted using Mplus v.8, with the full information maximum likelihood estimation method to account for missingness. Our projected sample size was 200 participants based on general recommendations of 5-10 subjects per parameter for path models.33 Indirect effects were assessed with bias-corrected bootstrapped confidence intervals (CIs) based on 2,000 samples. Path analysis was used to examine a parallel mediation model investigating whether meaning making and acceptance mediated relationships between perceived injustice and psycho-spiritual outcomes (i.e., depressive symptoms, anxiety, anger about cancer, anger towards God) (Figure 1). Based on prior research,2, 4-6 this model included the following covariates: age, gender, number of medical comorbidities, and functional status. This model was saturated; thus, we describe model interpretability and the direction and statistical significance of each path instead of model fit.
Figure 1.
Conceptual model depicting indirect effects of perceived injustice on psycho-spiritual outcomes through meaning making and acceptance.
Supplemental multiple group path analyses were conducted to explore potential differences in the relationships among the variables by cancer type. Two path analyses were conducted: first, all parameters were allowed to differ between the two cancer groups; second, all parameters were constrained to be equal between these groups. The two models were then compared using a Chi-square difference test. A significant test result would suggest that there was an overall difference between the two groups. Again, age, number of medical comorbidities, and functional status were included as covariates in these models. Gender was excluded here due to its limited variance among prostate cancer patients. For all analyses, p <0.05 was considered statistically significant.
Results
Supplemental Figure 1 shows the recruitment flow. Of the 377 patients who were sent recruitment mailings, 13 (3.4%) were deceased and 60 (15.9%) could not be reached. Of the 304 reached patients, 243 (79.9%) were screened for eligibility and 61 (20.1%) refused. The most common reasons for refusal were lack of interest and time. Of the 243 screened patients, 20 (8.2%) were ineligible. All of the 223 patients who were eligible consented to participate and 202 (90.6%) completed the survey. After survey completion, one person was found to be ineligible due to cancer stage and was omitted from the analyses. Participants and those who declined participation did not significantly differ with respect to age, gender, or race/ethnicity (ps>0.05).
Supplemental Table 1 shows patient characteristics. Patients were mostly non-Hispanic White (85%) and male (72%), with a mean age of 67 (SD=11). On average, patients were 3 years (SD=2.7) from their advanced cancer diagnosis. Cancer treatment history often included surgery (55%) and chemotherapy (49%). Most participants (88%) did not consider themselves to be terminally ill. Almost half of participants reported engaging in organizational religious activities (e.g., attending church) at least a few times a month (44%) and in non-organizational religious activities (e.g., praying) at least once a week (49%). Correlations between intrinsic religiosity and psycho-spiritual outcomes were nearly zero (ps>0.05).
The anger toward God variable was log-transformed to adjust for skewness prior to analyses. Table 1 shows descriptive statistics, Cronbach’s alphas, and bivariate correlations for main study variables. Alphas for all study measures were excellent. Most correlations were in the predicted directions (ps<0.05). However, correlations between meaning making and other variables were nearly zero (ps>0.05), except for its correlation with acceptance (r=0.16, p<0.05).
Table 1.
Descriptive statistics and bivariate correlations for main study variables (N = 201).
| Descriptive Statistics | Bivariate Correlations | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Variable | Mean (SD) | Range | α | 1. | 2. | 3. | 4. | 5. | 6. | 7. |
| 1. Depressive symptoms | 49.77 (8.45) | 41.00 - 69.50 | 0.90 | -- | ||||||
| 2. Anxiety | 51.05 (8.89) | 40.30 - 73.30 | 0.89 | 0.77** | -- | |||||
| 3. Anger about cancer | 9.14 (4.00) | 4.00 - 23.00 | 0.89 | 0.60** | 0.59** | -- | ||||
| 4. Anger toward God (log)† | 0.16 (0.36) | 0.00 - 1.61 | 0.96 | 0.29** | 0.21** | 0.37** | -- | |||
| 5. Perceived injustice | 14.14 (11.16) | 0.00 - 49.00 | 0.93 | 0.60** | 0.64** | 0.64** | 0.36** | -- | ||
| 6. Meaning making | 2.99 (0.90) | 1.00 - 4.00 | 0.90 | −0.08 | −0.04 | −0.06 | −0.09 | 0.00 | -- | |
| 7. Acceptance of cancer | 16.91 (3.29) | 4.00 - 20.00 | 0.84 | −0.45** | −0.45** | −0.49** | −0.29** | −0.50** | 0.16* | -- |
p < 0.05.
p < 0.01.
The anger toward God variable was positively skewed and was log-transformed prior to analyses.
Results provided partial support for our hypothesis (Figure 2). Perceived injustice was directly related to psycho-spiritual outcomes (βs=0.30 to 0.55, ps<0.01) and acceptance (β=−0.51, p<0.001). Acceptance was related to psycho-spiritual outcomes (βs=−0.15 to −0.24, ps<0.05). Bootstrapped 95% CIs showed significant indirect effects of perceived injustice on depressive symptoms (β=0.09, 95% CI[0.03,0.16]), anxiety (β=0.08, 95% CI[0.02,0.15]), anger about cancer (β=0.12, 95% CI[0.03,0.23]), and anger toward God (β=0.09, 95% CI[0.02,0.17]) through acceptance. Contrary to our hypothesis, meaning making was not significantly related to perceived injustice or psycho-spiritual outcomes (ps>0.05) and did not mediate the effects of perceived injustice on these outcomes.
Figure 2.
The parallel mediation model with standardized estimates depicting indirect effects of perceived injustice on psycho-spiritual outcomes through meaning making and acceptance.
Paths represented with solid lines are statistically significant at p < 0.05, and dashed lines are non-significant. Included covariates (age, gender, number of medical comorbidities, and functional status) are not shown for ease of presentation.
*p < 0.05. **p < 0.01. ***p < 0.001.
Supplemental multiple group path analyses showed no significant overall difference in the path coefficients between advanced lung and prostate cancer patients (Supplemental Table 2).
Discussion
This study examined a novel correlate of psycho-spiritual outcomes in advanced cancer—illness-related perceived injustice. We examined the relations between perceived injustice associated with advanced lung or prostate cancer and psycho-spiritual outcomes (i.e., depressive symptoms, anxiety, anger about cancer, anger toward God). Grounded in Park’s Meaning Making Model19 and Just World Theory,8 we expected that greater perceived injustice would be associated with poorer psycho-spiritual outcomes through lower meaning making and acceptance of cancer. Findings indicated that perceived injustice was directly associated with psycho-spiritual outcomes and indirectly related to these outcomes through acceptance, but not through meaning making. Findings were similar across advanced lung and prostate cancer patients.
We found that higher levels of perceived injustice were associated with worse psycho-spiritual outcomes for both lung and prostate cancer patients. These groups experience various cancer-specific stressors that may be perceived as unjust (e.g., smoking-related stigma, masculinity-related losses).11-13 According to Just World Theory, patients with greater perceived injustice may view the illness as violating their core assumption that the world is inherently predictable and fair.7-9 This shift in appraisals may be associated with greater catastrophizing and distress,9, 18 as found among patients with chronic pain and major depressive disorder.9, 17, 18, 34 Longitudinal studies with these populations have also found that perceived injustice is an antecedent of poor psychological outcomes.18, 34
Alternatively, psychological and spiritual struggles may lead to greater perceived injustice. For example, distressed lung cancer patients might engage in upward social comparisons35—comparing themselves to people who have smoked extensively without known health effects, which might lead to feelings of unfairness.35 Distressed cancer patients may also engage in maladaptive interpersonal behaviors such as seeking excessive reassurance or negative feedback (e.g., criticism) to confirm negative self-views.36 If this pattern persists, close others may reject or avoid the patient,36 contributing to the patient’s perceived injustice.
Contrary to our model, meaning making did not mediate relationships between perceived injustice and psycho-spiritual outcomes nor was it directly related to psycho-spiritual outcomes. It is possible that meaning making is not as central to psychological adjustment when illness is perceived as less threatening. Indeed, most of our participants (88%) did not classify their illness as terminal. When patients consider their illness to be curable, the discrepancies between global and situational meanings may be less severe, and other coping strategies (e.g., planning, problem-solving) may be more adaptive for their psychological adjustment. It is also possible that patients were not able to retrospectively assess their own meaning making process, as their average time since diagnosis was 3 years.
Meaning making also was not associated with perceived injustice. Although Park’s Meaning Making Model19 posits that discrepancies between situational and global meanings – a hallmark of perceived injustice – lead to meaning making, studies have found mixed evidence for the link between these appraisals and meaning making.19, 37 For example, among cancer survivors, reports that having cancer violated their belief in a just world were unrelated to meaning making.37
Our results suggest that acceptance of cancer may be a mediating process between perceived injustice and psycho-spiritual outcomes. Similar results were found for people with chronic pain; greater perceived injustice was associated with lower pain acceptance, which, in turn, was associated with poorer psychological outcomes.24 Results are consistent with conceptualizing acceptance as a coping strategy by which patients come to terms with their illness and its perceived unfairness, resulting in worse psycho-spiritual outcomes.22 Conversely, patients with elevated perceived injustice may be less able to make peace with their illness and engage in meaningful activities despite their illness. These patients may instead use coping strategies such as avoidance and emotional numbing that are associated with increased distress.38
Findings also suggest that cancer type may not impact the strength or direction of the relationship between perceived injustice and psycho-spiritual outcomes. Irrespective of their experiences related to cancer type, patients with greater perceived injustice may be more likely to experience worse psycho-spiritual outcomes. Alternatively, these findings may reflect power limitations or non-significant differences in main study variables between patient groups. Indeed, both groups reported similar levels of meaning making, acceptance, and psycho-spiritual outcomes.
Study Limitations
This study had limitations that may be addressed in future research. The majority of patients were non-Hispanic White, male, and Christian, and all were residing in the midwestern United States and had advanced lung or prostate cancer. Additionally, despite the relatively large sample size, there was limited power to examine cancer group differences. Findings warrant replication in larger samples and other cultural, gender, and cancer groups. Longitudinal designs would allow researchers to determine the directionality of associations. While we did not find significant relations between intrinsic religiosity and psycho-spiritual outcomes, future research could examine religiosity/spirituality and religious coping as potential mechanisms through which perceived injustice may impact psycho-spiritual outcomes. Researchers could also assess social withdrawal and loneliness as potential mechanisms.
The measurement of meaning making is another limitation. We used the COPE Positive Reinterpretation subscale,21 a common measure of meaning making focusing on positive reappraisal, personal growth, and learning from experience.19, 20 To more fully capture the meaning making process, future studies should longitudinally assess situational and global meanings, as meaning making can involve automatic/unconscious processing which is difficult to assess without longitudinal measures.20 Future studies should also assess meanings made and different meaning making processes (e.g., goal revision, problem-focused coping, activation of spiritual beliefs) starting around the time of diagnosis and throughout treatment.20 Self-report measures may also be supplemented with observer reports in future studies.
Clinical Implications
In clinical practice, clinicians may assess cancer patients’ perceived injustice, which could inform individualized treatment planning. Clinicians could discuss effective anger management strategies or, if appropriate, self-advocacy within the healthcare system. Informing medical staff of a patient’s perceived injustice might also prompt strategies to improve their working alliance with the patient. Additionally, findings provide preliminary support for targeting acceptance to reduce distress related to perceived injustice. Clinicians may use acceptance-based interventions to foster mindful awareness of injustice appraisals and cognitive defusion (i.e., disentangling from thoughts). Indeed, acceptance-based interventions have shown promise in improving psychological outcomes in cancer patients.39
Conclusions
Findings indicate that among advanced lung and prostate cancer patients, perceived injustice was directly associated with psycho-spiritual outcomes and indirectly related to these outcomes through acceptance of cancer. Meaning making was unrelated to perceived injustice and psycho-spiritual outcomes. Further research is needed to assess temporal relations among study variables. Examining the role of perceived injustice in psycho-spiritual outcomes across diverse cancer patients and identifying mediators of these relationships will inform the development and tailoring of future interventions to improve psychological adjustment to cancer.
Supplementary Material
Acknowledgements
This study was supported by the Walther Cancer Foundation [grant number 0172.01] and the National Cancer Institute [grant number T32CA117865]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Walther Cancer Foundation or the National Cancer Institute. We thank the study participants, medical staff, Gabriella Sblendorio, Cassie Petroff, and Isabella Stuart for their contributions to this project.
Footnotes
Conflicts of Interest: Ekin Secinti is presently employed at Eli Lilly and Company, Indianapolis, IN. This study was not financially supported by and does not necessarily represent the official views of Eli Lilly and Company. The authors declare that there is no conflict of interest.
Data Availability:
The datasets generated during and/or analyzed during the present study are available from the corresponding author on reasonable request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated during and/or analyzed during the present study are available from the corresponding author on reasonable request.