Association of spirituality and quality of life in cancer survivors: A systematic review and meta- analysis

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Firkins, Ivana Tomic, Lissi Hansen, Christopher D. Woodrell This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3911625/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 04 Mar, 2025 Read the published version in Supportive Care in Cancer → Version 1 posted 7 You are reading this latest preprint version Abstract Purpose: Cancer is a leading cause of morbidity and mortality worldwide. Although people are living longer with cancer, cancer has the potential to negatively impact survivors’ quality-of-life (QOL). Spirituality encompasses the concepts of transcendence, meaningfulness, faith, connectedness, and integrative energy. Spirituality is a part of everyday existence across cultures and religions and is a part of the human experience. Yet little has been published on spirituality in cancer survivorship. We were unable to find any previous reviews that examined the literature on the potential relationship between QOL and spirituality in cancer survivorship. Thus the aim of this systematic review and meta-analysis is to examine the current literature to more fully understand the relationship between spirituality and QOL. Methods: Using PRISMA guidelines, a systematic review and meta-analysis were conducted to examine the relationship between spirituality and QOL in cancer survivorship in studies sourced from PubMed, CINHAL, and PsycINFO databases. Results: Twenty-four articles, published between 2005 and 2023 were included for review. All studies included demonstrated a significant, positive correlation between QOL and spirituality with r values ranging from 0.15 to 0.817. Conclusion: Our findings suggest a positive correlation between higher spirituality and increased QOL among cancer survivors. Future research is needed to improve the understanding of this relationship and its mediators so that supportive oncologic interventions can be modified to address unmet needs and spiritual suffering. By better understanding the relationship between spirituality and QOL, we can move towards supporting the highest level of QOL possible for cancer survivors. cancer health-related quality of life oncology quality of life spirituality meta-analysis and systematic review Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Full Text Cancer is a leading cause of morbidity and mortality in the United States (U.S.) and worldwide [ 1 , 2 ]. It is estimated that there are 17 million U.S. cancer survivors, almost 2 million of whom were diagnosed in 2023 [ 1 ]. It was estimated that there would be 609,820 cancer related deaths in the U.S. in 2023, making cancer the second leading cause of death in the U.S. [ 1 ]. Cancer continues to have a high mortality worldwide as well, with over 10 million cancer deaths worldwide in 2020 [ 2 ]. With an estimated 19.3 million new cancer diagnosis (excluding nonmelanoma skin cancer) worldwide in 2020, cancer is a global health concern [ 2 ]. Much of the focus on outcomes in cancer therapeutics research centers on overall survival and time until disease progression. However, cancer and its treatment can have a significant negative impact on the quality of life (QOL) of cancer survivors [ 3 , 4 ]. Therefore, understanding the impact of cancer and its treatment on an individual and how it impacts QOL is a vital consideration in cancer survivorship to mitigate any threats to survivors’ QOL where possible [ 5 , 6 ]. QOL has been described as an overarching concept that includes all aspects of being [ 7 ]. The World Health Organization defined QOL as “a state of complete physical, mental, and social well-being” [ 8 ]. QOL can encompass the experience of life as a whole rather than from its parts [ 9 ]. In some QOL models, and for the purpose of this systematic review of the literature, spirituality is a core domain of QOL in cancer survivorship, along with physical, psychological, and social well-being [ 10 ]. Spirituality has been defined as “[arising] from an underlying state of spiritual health and is an expression of it, much like the color of one’s complexion and pulse rate are expressions of good (physical) health.” [ 11 ]. Spirituality is a multidimensional concept encompassing the components of transcendence, meaning and purpose, faith, and interconnectedness [ 11 , 12 ]. For cancer survivors facing a potentially life-limiting diagnosis, thoughts about life, death, and meaning are prevalent, potentially affecting thoughts of meaning in their life and illness [ 13 , 14 ]. Although many QOL models include a spirituality domain, current literature lacks a comprehensive and cohesive examination of the relationship between QOL and spirituality in cancer survivorship. A recent systematic review found that in adults with heart failure, spirituality correlated with a 20% reduction in mortality and that there was a potential relationship between spirituality and QOL in these adults [ 15 ]. Yet it is unknown if a similar relationship between spirituality and QOL exists in cancer survivorship. Thus, the aim of this systematic review and meta-analysis was to more completely understand the relationships between spirituality, QOL, and the domains of QOL as evidenced in the existing scientific literature. We completed a systematic review and meta-analysis with the objectives of synthesizing and evaluating the previously published evidence of the relationship between the spirituality domain and overall QOL in cancer survivorship. A clear understanding of these relationships has the potential to identify key knowledge gaps, paving the way for the development of future research and interventions to optimize or maintain cancer survivors’ spirituality and QOL. Methods This review and analysis were completed adhering to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses report (PRISMA) [ 16 ]. A literature search was conducted using CINHAL, PubMED, and PsycINFO databases. Search terms (See Appendix for search terms) and parameters were used based on a previously published systematic review examining spiritualty and QOL in adults with a history of cardiovascular disease [ 17 ]. No constraint was placed on publication year, however no results met criteria for inclusion that were published prior to 2005, and the search was conducted ending on July 1, 2023. Search results were imported into Rayyan, a web-based blinded systematic review application, and duplicates were removed [ 18 ]. The reviewers (JF and IT) independently reviewed titles and abstracts of articles and identified those to be included. Inclusion criteria were: available in English, participants diagnosed with cancer as adults, reported a specific population of cancer survivors, contained measurements of both QOL and spirituality, and reported the completion of a quantitative correlation of spirituality and QOL. Only articles that specifically provided the correlation for spirituality and QOL were included in this review and meta-analysis. Qualitative studies, case studies, narrative reviews, commentaries, letters, and non-patient reported metrics were excluded due to our focus on the quantitative relationship of spirituality and QOL. Full articles were obtained and reviewed by both reviewers who completed independent, blinded reviews. The independent reviews were unblinded , and consensus about articles that met inclusion criteria was reached (Fig. 1). Data were extracted (JF and IT) for relevant information including publication information, cancer type, geographic location, QOL assessment tool, spirituality assessment tool, sample size, sample demographics, mean QOL, and mean spirituality. Correlation coefficient scores of QOL and spirituality were extracted from the published articles and synthesized for the meta analysis. Meta-Analysis Correlation coefficients (r) and number of study participants (n) were extracted from all included articles. Standard error (SE) was calculated using the formula SE= (1-r 2 )/ (n-2). Correlation coefficients and SE were entered into statistical management program Stata version 16. Cumulative effect sizes and confidence intervals were calculated using a random-effects model. A random-effects model was used due to the heterogeneity between the studies included in this analysis [ 19 ]. When reporting cumulative effect sizes, the following guidelines were used: small ≥ 0.20, medium ≥ 0.50, large ≥ 0.80 [ 20 ]. Results Our initial literature search yielded 3,908 potential studies for inclusion, after removal of 801 duplicates. Preliminary review of titles and abstracts resulted in 410 full articles being screened for inclusion. Agreement was obtained on 25 articles and 1 abstract for inclusion in this review and meta-analysis. Two of the studies that met inclusion criteria were the results of the dataset [ 21 , 22 ]. For this review, both articles were included in the systematic review, however only one data set was included in the meta-analysis. Complete agreement was obtained between the two reviewers; there was no third reviewer needed. Systematic Review Included articles ranged in publication year from 2005 to 2023, with 17 (68%) published in the 5 years previous to this review [ 21 – 36 ]. Study sample size ranged from 30 participants [ 24 , 37 ] to 1,578 [ 38 ] participants with a total of 8,052 in all 24 included studies. Studies were conducted in 16 countries: one each in Australia [ 39 ], Iceland [ 24 ], Japan [ 27 ], Jordan [ 23 ], Lebanon [ 26 ], China [ 29 ], Cyprus [ 40 ], Indonesia [ 36 ], Netherlands [ 30 ], Poland [ 33 ], South Korea [ 32 ], and Malaysia [ 34 ]. Two countries each had two studies completed: Brazil [ 41 , 42 ] and Turkey [ 28 , 31 ]. Eight studies were conducted in the United States [ 21 , 22 , 25 , 35 , 37 , 43 – 45 ], with two studies done exclusively with a Native American population using the same data set [ 21 , 22 ]. The mean ages of study participants ranged from 47.9 years [ 23 ] to 66.0 years [ 32 ] of age. Five studies were completed in an exclusively female breast cancer population [ 23 , 34 , 36 , 37 , 41 ], one study was done exclusively with female study participants, however the specific cancer types were not specified [ 21 ]. Chen et al. (2021) included an exclusive female population diagnosed with gynecological cancers. The remaining 19 studies were completed in mixed gender populations [ 24 – 28 , 30 – 33 , 35 , 39 , 40 , 43 – 46 ]. No studies reported a gender other than male and female. Ten included articles reported the religious makeup of their sample [ 23 , 25 , 30 , 31 , 34 , 35 , 37 , 39 , 43 , 45 ]. Of those, three included an exclusive or almost exclusive Muslin population [ 23 , 31 , 34 ]. The remaining seven articles included a dominant Christian population, reporting specific breakdown of Christian sects [ 25 , 30 , 35 , 37 , 39 , 43 , 45 ]. Bai et al. (2015), Daugherty et al. (2005) and Whitford et al. (2008) reported a small percentage of study participants who identified as Jewish, 7.7%, 3%, and 0.2% respectively. No religions were reported outside of Muslin, Christian, and Jewish. All studies were completed with an outpatient cancer population. See Table 1 for a further breakdown of participant cancer type, gender, and religions of included articles. Table 1 Summary of full-text articles included in this systematic review First author (pub. year) Country [reference] Sample Size Cancer Types Study Design Gender Religion Spirituality Assessment Tool QOL Assessment Tool Correlation (p-value) Al-Natour (2017) Jordan [23] 150 Breast 100% Cross-sectional Female 100% Muslim 88.5% Christian 11.5% FACIT-SP FACT-G 0.67 (<0.001) Asgeidottir (2017) Iceland [24] 30 Lung 16.7% Breast 10% Gyn 10% Prostate 10% Colorectal 6.7% Head and Neck 6.7% Other 40% Cross-sectional Male 26.7% Female 73.3% Not reported EORTC QLQ-SWB EORTC QLQ-C30 0.386 (0.035) Bai (2018) United States [25] 102 Myeloma 22.5% Breast 17.6% Lung 16.7% Colo/Rectal/Prostate 14.7% Pancreatic 7.8% Other 20.5% Secondary Analysis Male 38.2% Female 61.8% Baptist 41.2 % Christian 23.5% Church of God in Christ 6.9% Catholic 4.9% Methodist 4.9% Jehovah's Witness 3.9% Muslim 2.9% None 2% Lutheran 1% FACIT-SP FACT-G 0.80 (<0.01) Bai (2016) United States [45] 52 % not disclosed Head and neck GI Lung Gyn Secondary Analysis Male 53.8% Female 46.3% None 21.2% Protestant 19.2% Catholic 50% Jewish 7.7% Other 1.9% FACIT-SP FACT-G 0.74 (<0.001) Brandao (2021) Brazil [41] 108 Breast 100% Cross-sectional Female 100% Not Reported WHOQOL-SRPB EORTC QLQ-C30 0.372 (<0.001) Chaar (2018) Lebanon [26] 115 Not Reported Cross-sectional Male 33% Female 67% Not Reported FACIT-SP EORTC QLQ-C30 0.271 (0.007) Chen (2021) China [29] 705 Ovarian 45.7% Cervical 29.4% Endometrial 13.3% Trophoblastic 5.4% Cross-sectional Female 100% Not Reported EORTC QLQ-SWB EORTC QLQ-C30 0.468 (<0.01) Damen (2021) Netherlands [30] 400 Not Reported Secondary Analysis Male 52% Female 48% Protestant or Catholic not church going 41% Protestant or Catholic church going 19% Other 40% FACIT-SP FACT-G 0.43 (<0.001) Daugherty (2005) United States [43] 162 GI 49% Lung 34% GYN/Urinary 20% Head and Neck 2% Other 18% Cross-sectional Male 55% Female 45% Catholic 53% Protestant 35% Jewish 3% Other 2% None 8% FACIT-SP FACT-G 0.36 (0.001) Del Giglio (2006) Brazil [46] 72 Not Reported Cross-sectional Male 36.1% Female 63.9% Not Reported FACIT-SP FACT-G Not Reported (0.025) Frost (2013) United States [44] 1578 Lung 100% Secondary Analysis Male 52.1% Female 47.9% Not Reported FACIT-SP SF-8 0.52 (not reported) Harbali (2022) Turkey [31] 406 Leukemia 27.8% Lymphoma 20.4% Lung 19.2% Breast 8.4% Colon 4.9% Pancreas 4.2% Other 15.1% Cross-sectional Male 56.9% Female 43.1% Muslim 100% Spiritual Orientation Scale FACT-G 0.193 (<0.01) Hsieh (2020) and Lee Y (2023) United States (Native American) [21, 22] 73 Not Reported Cross-sectional Female 100% Not Reported FACIT-SP FACT-G 0.58 (<0.01) Kamijo (2018) Japan [27] 176 Breast 38.6% Gyn 25.0% Pancreatic/liver/bile 15.3% Colorectal 9.7% Gastric 3.4% Lung 2.8% Urological 0.6% Thyroid 0.6% Other 4.0% Cross-sectional Male 25% Female 75% Not Reported FACIT-SP FACT-G 0.7146 (<0.001) Kyranou (2021) Cyprus [40] 104 Not Reported Cross-Sectional Male 43% Female 57% Not Reported EORTC QLQ-SWB EORTC QLQ-C30 0.15 (Not Reported) Leak (2008) United States [37] 30 Breast 100% Cross-sectional Female 100% Baptist 50% Pentecostal 6.7% Presbyterian 3.3% Muslin 3.3% Methodist 6.7% AME Zion 3.3% No affiliation 3.3% Other 23.3% Spiritual Perspective Scale Quality of Life Index 0.70 (<0.05) Lee, M (2021) South Korea [32] 132 Non-Small Cell Lung 100% Cross-Sectional Male 72% Female 28% Not Reported FACIT-SP EORTC QLQ-C30 0.39 (<0.0001) Majda (2022) Poland [33] 101 Not Reported Cross-Sectional Male 45% Female 55% Not Reported Daily Spiritual Experience Scale EORTC QLQ-C30 0.516 (<0.001) Pahlevan Sharif (2021) Malaysia [34] 145 Breast 100% Cross-Sectional Female 100% Muslin Beliefs and Values Scale McGIll 0.46 (<0.05) Puspita (2023) Indonesia [36] 112 Breast 100% Cross-Sectional Female 100% Not Reported FACIT-SP SF-36 0.817 (<0.001) Randazzo (2021) United States [35] 606 Breast 100% Cross-Sectional Female 100% Christian 73.9% Unknown 13.7% None 6.3% FACIT-SP FACT-G 0.66 (<0.0001) Whitford (2008) Australia [39] 449 Head/Neck 10.7% Urological 17.8% Breast 26.3% Colorectal 10.5% Lung 13.1% Lymphoma 13.1% Gyn 2.9% Sarcoma 1.1% Upper GI 4.0% CNS 0.7% Melanoma 4.5% Leukemia 0.7% Unknown 2.7% Other 2.2% Secondary analysis Male 51.9% Female 48.1% Christian 57.2% Jewish 0.2% Unknown 15.9% None 17.2% FACIT-SP FACT-G 0.59 (<0.001) Yilmaz (2020) Turkey [28] 150 GI 69.3% Breast/Thyroid 30.7% Cross-sectional Male 38.7% Female 61.3% Not Reported FACIT-SP FACT-G 0.619 (0.001) Spiritual Well-Being To assess spiritual well-being, the Functional Assessment in Chronic Illness Therapy – Spirituality Well-being (FACIT-SP) was used in the majority (68%) of included studies [ 21 – 23 , 25 – 28 , 30 , 32 , 35 , 36 , 39 , 43 – 46 ]. For studies that used the FACIT-SP, summary spiritual well-being scores ranged from 25.7 (SD 10.0) [ 32 ] to 79.3 (SD 18.46) [ 44 ]. The FACIT-SP general spiritual well-being scale scores range from 0 to 92, with 92 signifying higher levels of spiritual well-being. Three of the included articles that used the FACIT-SP for their measurement of spirituality did not report their overall mean spirituality score for their study population, however these studies were included based on their inclusion of a correlation coefficient for the relationship between spirituality and QOL [ 35 , 39 , 46 ]. Three of the included studies used the European Organization for Research and Treatment of Cancer Spirituality Scale (EORTC-SP) [ 24 , 29 , 40 ]. For the included studies that used the EORTC-SP, mean spirituality was 60.4 (SD 28.7) [ 40 ] and 72.48 (SD 34.99) [ 29 ]. An overall mean for spiritual well-being was not provided for one study, however the items means ranged from 2.63 (SD 0.61) to 3.33 (0.99) on a Likert-type scale from 1 (not at all) to 4 (very much) [ 24 ]. The EORTC-SP measures spirituality on a scale from 0 to 100, with 100 signifying a higher level of spirituality. One study used the Spirituality Perspective Scale [ 37 ]. The Spirituality Perspective Scale measures general spiritual well-being on a scale of 0 to 6, with 6 being high spiritual well-being. In this study the general spiritual well-being mean was 5.65 (SD 0.55) [ 37 ]. The Beliefs and Values Scale, a 10-item questionnaire, was also used once [ 34 ], by Pahelvan Sharif (2021) as their measurement of spirituality. The mean spirituality of their sample was not reported. The Daily Spiritual Experience Scale, was used once [ 33 ]. It is a 15 question measure utilizing a modified, six-point Liker-typet scale [ 47 ]. Cumulative scores range from 16 to 96, with higher number corresponding to higher spirituality [ 47 ]. Using the Daily Spiritual Experience Scale, Majda (2022) reported a mean spirituality of 65.22 (SD 21.05). Brandao (2021) used the World Health Organization Quality of Life Spirituality, Religiousness and Personal Beliefs Scale (WHOQOL-SRPB) with a mean spirituality score of 17.76 (SD 1.84) [ 41 ]. The WHOQOL-SRPB includes 32 Likert-style questions with a score between 0 and 20 with higher numbers signifying higher levels of spirituality [ 41 ]. The Spiritual Orientation Scale is a 7-item Likert-type scale with a range from 0 to 108, with higher values corresponding to higher levels of spirituality [ 31 ]. Harbali (2022) found the mean spirituality of their sample using the Spiritual Orientation Scale to be 87.9 (SD 18.5). See Table 2 for complete breakdown of measurements of spirituality. Table 2 Measurements of Spirituality included in Review Measure # of items Subscales Validated Languages Validated Disease Population Validated Religious Populations Reliability from original factor analysis EORTC-SP 32 Relationship with others, Relationship with self, Relationship with something greater, Existential, Relationship with God if applicable Bengali, Chinese, Croatian, Dutch, English, Finnish, French, German, Greek, Icelandic, Italian, Japanese, Norwegian, Persian, Portuguese, Russian, Spanish, Slovak, Swahili, Swedish, and Vietnamese [ 67 ] Cancer [ 68 ] Abrahamic Religions [ 68 ] 0.7 [ 68 ] FACIT-SP 23 Meaning, Peace, and Faith along with general measurement of spirituality Arabic, Bengali, Burmese, Chinese, Croatian, Czech, Danish, Dutch, English, Farsi, French, German, Greek, Hebrew, Hindi, Hungarian, Indonesian, Italian, Japanese, Korean, Lithuanian, Malay, Malayalam, Marathi, Nepali, Norwegian, Polish, Portuguese, Serbian, Sinhalese, Spanish, Slovak, Slovene, Swahili, Swedish, Tamil, Telugu, Thai, Turkish, and Vietnamese [ 69 ] Cancer, HIV/AIDS [ 70 ] Diabetes, Heart disease, Thyroid disease, Rheumatoid arthritis, COPD [ 71 ] Cystic fibrosis [ 72 ] Orthopedic disease [ 73 ] Psychiatric disorders [ 74 ] Judo-Christian[ 75 , 76 ] Buddhism [ 73 ] Islam [ 77 ] 0.88 [ 70 ] Spirituality Perspective Scale 10 N/A Arabic [ 78 ], Chinese [ 79 ], English, Italian [ 80 ], Korean [ 81 ], Persian [ 82 ], and Spanish [ 83 ] Terminally Ill [ 84 ] Chronic Kidney disease [ 85 ] Pregnancy [ 86 ] Abrahamic Religions [ 84 ] 0.89 [ 84 ] Beliefs and Values Scale 10 N/A Arabic [ 87 ] and English Cancer Abrahamic Religions, Hinduism, and Buddhism 0.94 [ 88 ] Daily Spiritual Experience 16 N/A Arabic, Czech, Danish, Dutch, English, Flemish, Filipino, French, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Latvian, Lithuanian, Malay, Malayalam, Nepalese, Persian, Polish, Romanian, Russian, Serbian, Slovenian, Thai, Turkish, Ukrainian, Urdu, and Vietnamese [ 89 ] Not specified Judo-Christian [ 90 ] 0.9 [ 90 ] WHOQOL 32 N/A Arabic, Chinese, Croatian, Czech, Danish, Dari, Dutch, English, French, German, Hindi, Hungarian, Italian, Japanese, Kiswahili, Korean, Lithuanian, Norwegian, Polish, Portuguese, Russian, Serbian, Sinhala, Spanish, Swedish, and Turkish [ 91 ] Not specified Not specified 0.85 [ 92 ] Spiritual Orientation Scale 7 N/A Turkish [ 31 ] Unknown Unknown 0.87 [ 31 ] Quality of Life The Functional Assessment of Cancer Treatment – General (FACT-G) was the most commonly used measurement of overall QOL (n = 11, 48%) [ 21 , 23 , 25 , 27 , 28 , 31 , 35 , 39 , 43 , 45 , 46 ]. The European Organization for Research and Treatment of Cancer Comprehensive Quality of Life (EORTC – QOL- C30) was used in eight studies (32%) [ 24 , 26 , 29 , 30 , 32 , 33 , 40 , 41 ]. The EORTC-QOL-C30 summary of QOL score ranges from 0 to 100 with 100 signifying a higher QOL. In this review, EORTC-QOL-C30 study summary QOL score ranged from 45.2 (SD 24.0) [ 40 ] to 78.86 (SD 18.56) [ 41 ]. The Short Form 8 (SF-8) [ 44 ] and Short Form 36 (SF-36) were each used in a single study. The SF-8 and SF-36 both have a range from 0 to 100, with 100 signifying higher QOL. For the article included in this review, the mean QOL score on the SF-8 was 80 [ 44 ], the QOL mean for the SF-36 [ 36 ] was not reported in study results. One study each used the McGill Scale [ 34 ], and Quality of Life Index [ 37 ]. For the Quality of Life Index, a range of 0 to 30 with 30 signifying higher quality of life, was used in a single study with a mean QOL of 26.6 (SD 2.92) [ 37 ]. The FACT-G is a commonly used QOL measurement tool designed specifically for use in the cancer population [ 48 ]. It includes 27 Likert-style questions and has subscales of physical, social, emotional, and function well-being. It is an international measure having been validated and translated into 74 languages [ 49 ]. Original psychometric testing of the FACT-G had good internal reliability [ 50 ]. The EORTC-QLQ-C30 was the second most commonly used measurement tool for QOL in the articles included in this review. The EORTC-QLQ-C30 is another well-established, reliable and valid QOL measure specifically designed for the cancer population [ 48 ]. The EORTC-QLQ-C30 has been translated and validated in 117 international languages. In addition to a general subscale of global health/QOL, the EORT-QLQ-C30 includes five functional subscales of physical, role, emotional, cognitive, and social. This QOL measurement tool also includes nine symptom subscales of fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties [ 51 ].The SF 8 is a shorten form of the SF 36, both of these measure are highly established measurements of QOL in varying setting of disease and health. Similar to the two QOL measure previously discussed, the SF 8 and SF 36 are international measures that have been validated in over 50 languages in over 25 countries. Both the SF 8 and SF 36 have eight subscales including physical functioning, social functioning, role limitations physical, general medical health, mental health, role limitations emotional, vitality, and bodily pain address the psychological domain, and only 15% (n = 11) address the social domain (remaining 10% (n = 7) address global QOL) [ 52 ]. Although less commonly used than the previously discussed measurement tools of QOL, the McGill scale and the Quality of Life Index are both well-established tools to measure QOL. The McGill scale was designed to examine QOL in adults facing a life-limiting illness, specifically adults with cancer or HIV/AIDS. The McGill scale is a 14 item questionnaire with four subscales including physical functioning, existential, social, and psychological [ 53 ]. Internal reliability for the McGill scale is 0.94 [ 53 ]. In addition to English, the McGill scale has been validated in Arabic [ 54 ], Chinese [ 55 ], Italian [ 56 ], Korean [ 57 ], and Spanish [ 58 ]. The Quality of Life Index is a valid QOL measure with an internal reliability of 0.96 [ 59 ]. The Quality of Life Index is a five item questionnaire includes four subscales of health and function, psychological/spiritual, social and economic, and family [ 59 ]. Spirituality and QOL Subscales Thirteen of the included articles included correlations associated with the measurement subscales of QOL in addition to reporting the overall correlation between spirituality and QOL [ 23 , 26 – 31 , 33 , 38 – 40 , 43 , 45 ]. Seven of these studies examined QOL using the FACT-G [ 23 , 27 , 28 , 31 , 39 , 43 , 45 ]. Five utilized the EORTC-QLQ-C30 as their QOL measurement [ 26 , 29 , 30 , 33 , 40 ]. Frost et al. (2013) used the SF-8 as their measurement of QOL. Of the 13 articles that included measurement subscales of QOL in their analysis, eight also included subscales of their spirituality measurement in their correlation analysis [ 26 – 30 , 39 , 40 , 45 ]. Of these eight articles, six examined spirituality through the FACIT-SP [ 26 – 28 , 30 , 39 , 45 ] and two through the EORTC-QLQ-SWB [ 29 , 40 ]. Meta-Analysis Correlation of Spiritual Well-Being and Quality of Life Correlations (r) between QOL and spirituality ranged from 0.817 [ 36 ] to 0.15 [ 40 ] in the included studies. One study was an abstract only and did not report the correlation, however the p-value was given as 0.025 [ 46 ]. All correlations were positive and statistically significant with a p-values of less than 0.05. These positive correlations signify that with higher spirituality, QOL was also higher. It is important to note that these results do not signify a causal relationship due to the limitations of correlations. Kyronou et al. (2021), Harbali et al. (2022), Chaar et al. (2018), Daugherty et al. (2005), Brandao et al. (2021), Asgeirdottir et al. (2017) and Lee et al. (2021) all found a definite, but small, positive correlations based on r’s of 0.15, 0.193, 0.271, 0.36, 0.372, 0.386 and 0.39 respectively [ 60 ]. Eleven included articles had a moderate correlation with a substantial relationship with r’s between 0.43 and 0.67 [ 21 , 23 , 28 – 30 , 33 – 35 , 39 , 44 , 60 ]. The remaining articles included in this review, Leak et al. (2008), Kamijo et al. (2018), Bai et al. (2015 and 2018), and Puspita et al. (2023) had high correlations between spirituality and QOL with values of 0.7, 0.715, 0.74, 0.80, and 0.817 respectfully [ 60 ]. The cumulative effect size demonstrated a moderate, substantial relationship between spirituality and QOL in cancer survivors (CES = 0.527; CI 0.463, 0.591; p < 0.001) (Fig. 2 ) [ 60 ]. Correlation of Spiritual Well-Being and Quality of Life Subscales QOL Subscales The measurement domains of QOL included a combination of those of the FACT-G and the EORTC-QOL-C30, namely: physical health, social health, functional health, and emotional health. Frost (2013) did not include the domains of function or emotional health in their analysis. A small but definite relationship was found between physical health and spirituality (CES = 0.242; CI 0.191, 0.293; p < 0.001) (Fig. 3 ) along with social health and spirituality (CES = 0.323; CI 0.259, 0.388; p < 0.001) (Fig. 4 ). A substantial relationship was found between functional health and spirituality (CES = 0.444; CI 0.306, 0.582; p < 0.001) (Fig. 5 ) along with emotional health and spirituality (CES = 0.437; CI 0.389, 0.486; p < 0.001) (Fig. 6 ). Spirituality Subscales For this meta-analysis, only the spirituality subscales of the FACIT-SP are reported here due to the EORTC-QLQ-SWB being used in only two articles. As previously mentioned, the FACIT-SP includes three subscales: meaning, peace, and faith. A substantial relationship was found between meaning and overall QOL (CES = 0.599; CI 0.557, 0.642; p < 0.001) and peace and overall QOL (CES = 0.614; CI 0.572, 0.656; p < 0.001). Faith and overall QOL were found to have a small, but significant relationship (CES = 0.279; CI 0.228, 0.329; p < 0.001). Substantial relationships were also found between meaning and emotional well-being (CES = 0.414; CI 0.365, 0.463; p < 0.001) along with peace and emotional well-being (CES = 0.485; CI 0.438, 0.532; p < 0.001). See Table 3 for the cumulative effect sizes for the subscales of spirituality and QOL. Table 3 Cumulative effect sizes and confidence intervals for spirituality and QOL subscales Physical Well-Being Emotional Well-Being Social Well-Being Meaning 0.314 (0.263, 0.365 0.414 (0.365, 0.463) 0.365 (0.315, 0.414) Peace 0.320 (0.269, 0.371) 0.485 (0.438, 0.532) 0.374 (0.325, 0.424) Faith 0.151 (0.099, 0.204) 0.219 (0.167, 0.271) 0.176 (0.124, 0.229) Note: all results had a p < 0.001 Discussion This systematic review and meta-analysis found evidence of a significant, positive correlation between spirituality and QOL in cancer survivors. All of the included studies found a positive correlation between spirituality and QOL to be statistically significant, and a significant, moderate relationship based on the cumulative effect size. The results of this review indicate that it may be possible to improve the QOL of cancer survivors by improving their spirituality. A similar systematic review examining the relationship between spirituality and QOL in cardiovascular disease found slightly different results than those of cancer survivors, with approximately half of the studies included in the review of cardiovascular disease reporting negative or null correlations between spirituality and QOL in adults with cardiovascular disease [ 17 ]. Previous cancer research has found that despite significant advances in cancer diagnosis and treatment, the very diagnosis of cancer continues to result in “existential plight” or a specific search for meaning following the diagnosis of cancer [ 61 ]. The difference in these two reviews may be due to a diagnosis of cancer resulting in an influx of thoughts concerning one’s own potential for existence or nonexistence that is not seen in other, similar life limiting, medical diagnoses such as cardiovascular disease [ 61 , 62 ]. The phenomena of “existential plight” may aid in explaining the difference between these two reviews and aid in better understanding the relationship between spirituality and QOL in cancer survivorship. Our findings suggest a positive correlation between increased levels of spirituality and QOL among cancer survivors. Future research is needed to improve the understanding of this relationship and its mediators so that supportive oncologic interventions can be modified to address unmet needs and spiritual suffering. Previous research has shown that increased spirituality is a significant coping mechanism that provides protection against depression [ 63 ]. Although not addressed in this review, it is possible that this effect may be stronger in cancer survivor facing a high mortality cancer due to the increased potential for death from the disease resulting in increased introspection and life evaluation [ 61 ]. More research is needed to examine the relationship between spirituality and QOL based on disease severity and/or stage of disease. The positive and statistically significant correlation between the domains of QOL and spirituality further demonstrates the positive relationship between these two variables. It is important to note that all of the relationships between the measurement domains and spirituality were weaker than the relationship between overall QOL and spirituality. These results may help us better understand the intricacies of the relationship between QOL of spirituality. Results demonstrated that the weakest relationship was between physical health and spirituality while the strongest relationship was between emotional heath and spirituality. Although more research is needed, this may provide insight into using and intervening on spirituality in order to impact and improve QOL, especially when taking into consideration the potential protective effects of spirituality on depression discussed previously. Currently, the cancer survivor literature lacks a standard measurement tool(s) for the evaluation of spirituality in cancer survivorship. One reason for this may be the variability of spirituality measurement tools and lack of a concise definition of spirituality in the current literature. Although spirituality measurement tools have been translated and had those translations validated in a wide variety of languages, the original factor analysis and measurement designs were done in limited populations. Only a single measurement of spirituality contained an international population in their study development with the WHOQOL-SRPB including study participants from every inhabited continent in their measurement design and factor analysis validation studies. However, the WHOQOL combines the concepts of spirituality, religious and person beliefs in their measurement scale. With spirituality and religiosity being two separate, yet related concepts this combination may be a barrier separating the concepts of spirituality and religiosity in cancer survivor research. Of the spirituality measurement tools in the review, those that reported religious affiliation of study participants for the primary validation studies, religious affiliation was almost exclusively that of Abrahamic religions (Christianity, Islam, and Judaism). There is a need for a spirituality measure tool that crosses all national borders and religious affiliations in order to truly understand and examine spirituality in the cancer survivorship population. As previously discussed, better understanding spirituality may be a key component in order to truly understand and examine QOL in cancer survivors. The results of this meta-analysis suggest that meaning and peace are the strongest aspects of spirituality that positively impact QOL, however a limitation to this finding is the subscales of spirituality study measurements. As previously mentioned, the core concept of spirituality are transcendence, meaningfulness and purposefulness, faithfulness, harmonious interconnectedness, holistic being, and integrative energy. Of the seven measurement tools of spirituality, only two included scoring for subscales (FACIT-SP and EORTC-QLQ-SWB. The subscales of the EORTC-QLQ-SWB focused on the relationship aspect of spirituality with relationship to self, others, and something greater than oneself as the key subscales. However, these subscales do not capture key concepts of spirituality such as meaningfulness and purposefulness. However, though the FACIT-SP subscales include meaning and peace, it does not examine the relationship aspect of spirituality found in the EORTC-QLQ-SWB. More research is needed into the subscale of spirituality in order to more completely understand their relationship to QOL. Additional research may also be needed into instrument development around spirituality in order to more accurately measure the concepts of spirituality in cancer survivorship. Clinical Implications Despite the demonstrated relationship between spirituality and QOL, cancer survivors have reported that their healthcare providers discuss spirituality and spiritual well-being infrequently with them [ 64 ]. A study of providers and adults with advanced illnesses found that providers frequently ‘miss the moment’ to address spirituality and spiritual well-being with patients due to feeling that spiritual care is not something that the health care provider, could provide [ 65 ]. Additionally, an international qualitative study found that a key research priority for adults with life-limiting diseases was spirituality and provider education regarding addressing patient spirituality [ 66 ]. It is clear that spirituality plays a key and important role in cancer survivors QOL, yet the results of this review demonstrate the need to better understand the role that spirituality has in QOL including the different multidimensional concepts of spirituality. Limitations This is the first systematic review to examine the relationship between spirituality and QOL in cancer survivors. However, there are several limitations of this review. We excluded non-English articles, potentially leading to publication bias. Another limitation is the heterogeneity of the types of cancers included in the reviewed studies. QOL and survivability in cancer can vary extensively between cancer types, even within the same cancer type due to stage of disease. Due to that, we were unable to determine if there is a relationship between cancer types and the correlation between spirituality and QOL, further studies are needed to examine these relationships further. Lastly, though there is strong evidence of a correlation between spirituality and QOL in cancer survivorship, our results do not address potential moderators or mediators to the relationship impacting spirituality and QOL. Again, more research is needed to address and examine potential moderators and mediators that potentially impact the relationship between spirituality and QOL. Conclusion In conclusion, the results of this review demonstrate the association between spirituality and QOL. Further research is needed in order to have a more complete and in-depth understanding of this relationship and the impact on this relationship for cancer survivors. By addressing spirituality, we, as healthcare providers may move towards supporting cancer survivors to experience and live at the highest level of QOL possible. Declarations This work was supported by the Innovation Grant from the School of Nursing at Oregon Health & Science University. None of the authors have any conflict of interest to report or disclose. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. 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Statements & Declarations This work was supported by the Innovation Grant from the School of Nursing at Oregon Health & Science University. None of the authors have any conflict of interest to report or disclose. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. The first draft of the manuscript was written by Jenny Firkins and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. The dataset generated as part of this review and meta-analysis are available from the corresponding author on reasonable request. Additional Declarations No competing interests reported. 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Woodrell","email":"","orcid":"","institution":"Icahn School of Medicine at Mount Sinai","correspondingAuthor":false,"prefix":"","firstName":"Christopher","middleName":"D.","lastName":"Woodrell","suffix":""}],"badges":[],"createdAt":"2024-01-30 19:59:48","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3911625/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3911625/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00520-025-09306-y","type":"published","date":"2025-03-04T15:57:55+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":51209056,"identity":"dd8116bd-93e5-4b0c-b511-99e6077bf8e6","added_by":"auto","created_at":"2024-02-16 04:26:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":38135,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram for systematic review methodology in accordance with PRISM guidelines\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/77846d6447423aec3e54dc54.png"},{"id":51208686,"identity":"c743e136-7517-40b5-aa71-585d8ed2c815","added_by":"auto","created_at":"2024-02-16 04:18:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":114050,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot of cumulative effect size of correlation between QOL and spirituality\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/ad53e0cc94913c8ee2cb7ccd.png"},{"id":51209058,"identity":"d8b0ef37-e24d-4d26-91f1-d0364c7cd73a","added_by":"auto","created_at":"2024-02-16 04:26:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":65192,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot of cumulative effect size of correlation between physical health and spirituality\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/1f89cf69ebe4597e271bbe14.png"},{"id":51208688,"identity":"034af40f-c5e8-4854-908e-812a61ea4fe1","added_by":"auto","created_at":"2024-02-16 04:18:41","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":64476,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot of cumulative effect size of correlation between social health and spirituality\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/918b119eeafb178439f22dec.png"},{"id":51208691,"identity":"66ebf22f-6f9a-47d5-91b1-c6b410eed930","added_by":"auto","created_at":"2024-02-16 04:18:42","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":60347,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot of cumulative effect size of correlation between functional health and spirituality\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/c3ca84fe78e0e5b7b1631353.png"},{"id":51208690,"identity":"2f6f2918-9ec9-4396-90b5-d42d01c20660","added_by":"auto","created_at":"2024-02-16 04:18:41","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":61117,"visible":true,"origin":"","legend":"\u003cp\u003eForrest plot of cumulative effect size of correlation between emotional health and spirituality\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/9e2df9ab99a7b3e263051001.png"},{"id":78191381,"identity":"15aa4cf4-041f-4463-a6da-d8cf9efb046a","added_by":"auto","created_at":"2025-03-10 19:58:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1973910,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/f7d49bb8-e0e3-434a-951f-cf21693fc510.pdf"},{"id":51209057,"identity":"93a1b2fb-2f92-4c63-b541-0d8f7e583eb8","added_by":"auto","created_at":"2024-02-16 04:26:41","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":12255,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-3911625/v1/ce2c6287bd9f23bb5055b764.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Association of spirituality and quality of life in cancer survivors: A systematic review and meta- analysis","fulltext":[{"header":"Full Text","content":"\u003cp\u003eCancer is a leading cause of morbidity and mortality in the United States (U.S.) and worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. It is estimated that there are 17\u0026nbsp;million U.S. cancer survivors, almost 2\u0026nbsp;million of whom were diagnosed in 2023 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It was estimated that there would be 609,820 cancer related deaths in the U.S. in 2023, making cancer the second leading cause of death in the U.S. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Cancer continues to have a high mortality worldwide as well, with over 10\u0026nbsp;million cancer deaths worldwide in 2020 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. With an estimated 19.3\u0026nbsp;million new cancer diagnosis (excluding nonmelanoma skin cancer) worldwide in 2020, cancer is a global health concern [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMuch of the focus on outcomes in cancer therapeutics research centers on overall survival and time until disease progression. However, cancer and its treatment can have a significant negative impact on the quality of life (QOL) of cancer survivors [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, understanding the impact of cancer and its treatment on an individual and how it impacts QOL is a vital consideration in cancer survivorship to mitigate any threats to survivors\u0026rsquo; QOL where possible [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. QOL has been described as an overarching concept that includes all aspects of being [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The World Health Organization defined QOL as \u0026ldquo;a state of complete physical, mental, and social well-being\u0026rdquo; [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. QOL can encompass the experience of life as a whole rather than from its parts [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn some QOL models, and for the purpose of this systematic review of the literature, spirituality is a core domain of QOL in cancer survivorship, along with physical, psychological, and social well-being [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Spirituality has been defined as \u0026ldquo;[arising] from an underlying state of spiritual health and is an expression of it, much like the color of one\u0026rsquo;s complexion and pulse rate are expressions of good (physical) health.\u0026rdquo; [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Spirituality is a multidimensional concept encompassing the components of transcendence, meaning and purpose, faith, and interconnectedness [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. For cancer survivors facing a potentially life-limiting diagnosis, thoughts about life, death, and meaning are prevalent, potentially affecting thoughts of meaning in their life and illness [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough many QOL models include a spirituality domain, current literature lacks a comprehensive and cohesive examination of the relationship between QOL and spirituality in cancer survivorship. A recent systematic review found that in adults with heart failure, spirituality correlated with a 20% reduction in mortality and that there was a potential relationship between spirituality and QOL in these adults [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Yet it is unknown if a similar relationship between spirituality and QOL exists in cancer survivorship. Thus, the aim of this systematic review and meta-analysis was to more completely understand the relationships between spirituality, QOL, and the domains of QOL as evidenced in the existing scientific literature. We completed a systematic review and meta-analysis with the objectives of synthesizing and evaluating the previously published evidence of the relationship between the spirituality domain and overall QOL in cancer survivorship. A clear understanding of these relationships has the potential to identify key knowledge gaps, paving the way for the development of future research and interventions to optimize or maintain cancer survivors\u0026rsquo; spirituality and QOL.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis review and analysis were completed adhering to the guidelines provided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses report (PRISMA) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. A literature search was conducted using CINHAL, PubMED, and PsycINFO databases. Search terms (See \u003cspan refid=\"Sec17\" class=\"InternalRef\"\u003eAppendix\u003c/span\u003e for search terms) and parameters were used based on a previously published systematic review examining spiritualty and QOL in adults with a history of cardiovascular disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. No constraint was placed on publication year, however no results met criteria for inclusion that were published prior to 2005, and the search was conducted ending on July 1, 2023. Search results were imported into Rayyan, a web-based blinded systematic review application, and duplicates were removed [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The reviewers (JF and IT) independently reviewed titles and abstracts of articles and identified those to be included. Inclusion criteria were: available in English, participants diagnosed with cancer as adults, reported a specific population of cancer survivors, contained measurements of both QOL and spirituality, and reported the completion of a quantitative correlation of spirituality and QOL. Only articles that specifically provided the correlation for spirituality and QOL were included in this review and meta-analysis. Qualitative studies, case studies, narrative reviews, commentaries, letters, and non-patient reported metrics were excluded due to our focus on the quantitative relationship of spirituality and QOL.\u003c/p\u003e \u003cp\u003eFull articles were obtained and reviewed by both reviewers who completed independent, \u003cem\u003eblinded\u003c/em\u003e reviews. The independent reviews were \u003cem\u003eunblinded\u003c/em\u003e, and consensus about articles that met inclusion criteria was reached (Fig.\u0026nbsp;1). Data were extracted (JF and IT) for relevant information including publication information, cancer type, geographic location, QOL assessment tool, spirituality assessment tool, sample size, sample demographics, mean QOL, and mean spirituality. Correlation coefficient scores of QOL and spirituality were extracted from the published articles and synthesized for the meta analysis.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eMeta-Analysis\u003c/h2\u003e \u003cp\u003eCorrelation coefficients (r) and number of study participants (n) were extracted from all included articles. Standard error (SE) was calculated using the formula SE= (1-r\u003csup\u003e2\u003c/sup\u003e)/ (n-2). Correlation coefficients and SE were entered into statistical management program Stata version 16. Cumulative effect sizes and confidence intervals were calculated using a random-effects model. A random-effects model was used due to the heterogeneity between the studies included in this analysis [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. When reporting cumulative effect sizes, the following guidelines were used: small\u0026thinsp;\u0026ge;\u0026thinsp;0.20, medium\u0026thinsp;\u0026ge;\u0026thinsp;0.50, large\u0026thinsp;\u0026ge;\u0026thinsp;0.80 [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOur initial literature search yielded 3,908 potential studies for inclusion, after removal of 801 duplicates. Preliminary review of titles and abstracts resulted in 410 full articles being screened for inclusion. Agreement was obtained on 25 articles and 1 abstract for inclusion in this review and meta-analysis. Two of the studies that met inclusion criteria were the results of the dataset [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. For this review, both articles were included in the systematic review, however only one data set was included in the meta-analysis. Complete agreement was obtained between the two reviewers; there was no third reviewer needed.\u003c/p\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003eSystematic Review\u003c/h2\u003e\n\u003cp\u003eIncluded articles ranged in publication year from 2005 to 2023, with 17 (68%) published in the 5 years previous to this review [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e]. Study sample size ranged from 30 participants [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e] to 1,578 [\u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e] participants with a total of 8,052 in all 24 included studies. Studies were conducted in 16 countries: one each in Australia [\u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e], Iceland [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e], Japan [\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e], Jordan [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e], Lebanon [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e], China [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e], Cyprus [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e], Indonesia [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e], Netherlands [\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e], Poland [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e], South Korea [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e], and Malaysia [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. Two countries each had two studies completed: Brazil [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e42\u003c/span\u003e] and Turkey [\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Eight studies were conducted in the United States [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e], with two studies done exclusively with a Native American population using the same data set [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e22\u003c/span\u003e]. The mean ages of study participants ranged from 47.9 years [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e] to 66.0 years [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] of age. Five studies were completed in an exclusively female breast cancer population [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e], one study was done exclusively with female study participants, however the specific cancer types were not specified [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e]. Chen et al. (2021) included an exclusive female population diagnosed with gynecological cancers. The remaining 19 studies were completed in mixed gender populations [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. No studies reported a gender other than male and female. Ten included articles reported the religious makeup of their sample [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Of those, three included an exclusive or almost exclusive Muslin population [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e]. The remaining seven articles included a dominant Christian population, reporting specific breakdown of Christian sects [\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Bai et al. (2015), Daugherty et al. (2005) and Whitford et al. (2008) reported a small percentage of study participants who identified as Jewish, 7.7%, 3%, and 0.2% respectively. No religions were reported outside of Muslin, Christian, and Jewish. All studies were completed with an outpatient cancer population. See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e for a further breakdown of participant cancer type, gender, and religions of included articles.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSummary of full-text articles included in this systematic review\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eFirst author (pub. year) \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCountry [reference]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e\u003cstrong\u003eCancer Types\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003e\u003cstrong\u003eReligion \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003e\u003cstrong\u003eSpirituality Assessment Tool\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003e\u003cstrong\u003eQOL Assessment Tool\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e\u003cstrong\u003eCorrelation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(p-value)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eAl-Natour (2017)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJordan \u003c/strong\u003e\u003cstrong\u003e[23]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eMuslim 88.5%\u003c/p\u003e\n\u003cp\u003eChristian 11.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.67\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eAsgeidottir (2017)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIceland \u003c/strong\u003e\u003cstrong\u003e[24]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung 16.7%\u003c/p\u003e\n\u003cp\u003eBreast 10%\u003c/p\u003e\n\u003cp\u003eGyn 10%\u003c/p\u003e\n\u003cp\u003eProstate 10%\u003c/p\u003e\n\u003cp\u003eColorectal 6.7%\u003c/p\u003e\n\u003cp\u003eHead and Neck 6.7%\u003c/p\u003e\n\u003cp\u003eOther 40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 26.7%\u003c/p\u003e\n\u003cp\u003eFemale 73.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eEORTC QLQ-SWB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.386\u003c/p\u003e\n\u003cp\u003e(0.035)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eBai (2018)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[25]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e102\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eMyeloma 22.5%\u003c/p\u003e\n\u003cp\u003eBreast 17.6%\u003c/p\u003e\n\u003cp\u003eLung 16.7%\u003c/p\u003e\n\u003cp\u003eColo/Rectal/Prostate 14.7%\u003c/p\u003e\n\u003cp\u003ePancreatic 7.8%\u003c/p\u003e\n\u003cp\u003eOther 20.5%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eSecondary Analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 38.2%\u003c/p\u003e\n\u003cp\u003eFemale 61.8%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eBaptist 41.2 %\u003c/p\u003e\n\u003cp\u003eChristian \u0026nbsp;23.5%\u003c/p\u003e\n\u003cp\u003eChurch of God in Christ 6.9%\u003c/p\u003e\n\u003cp\u003eCatholic 4.9%\u003c/p\u003e\n\u003cp\u003eMethodist 4.9%\u003c/p\u003e\n\u003cp\u003eJehovah's Witness 3.9%\u003c/p\u003e\n\u003cp\u003eMuslim 2.9%\u003c/p\u003e\n\u003cp\u003eNone 2%\u003c/p\u003e\n\u003cp\u003eLutheran 1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.80\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.01)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eBai (2016)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[45]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003e% not disclosed\u003c/p\u003e\n\u003cp\u003eHead and neck\u003c/p\u003e\n\u003cp\u003eGI\u003c/p\u003e\n\u003cp\u003eLung\u003c/p\u003e\n\u003cp\u003eGyn\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eSecondary Analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 53.8%\u003c/p\u003e\n\u003cp\u003eFemale 46.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNone 21.2%\u003c/p\u003e\n\u003cp\u003eProtestant 19.2%\u003c/p\u003e\n\u003cp\u003eCatholic 50%\u003c/p\u003e\n\u003cp\u003eJewish 7.7%\u003c/p\u003e\n\u003cp\u003eOther 1.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.74\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eBrandao (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBrazil \u003c/strong\u003e\u003cstrong\u003e[41]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e108\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eWHOQOL-SRPB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.372\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eChaar (2018)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLebanon \u003c/strong\u003e\u003cstrong\u003e[26]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e115\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 33%\u003c/p\u003e\n\u003cp\u003eFemale 67%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.271\u003c/p\u003e\n\u003cp\u003e(0.007)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eChen (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChina \u003c/strong\u003e\u003cstrong\u003e[29]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e705\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eOvarian 45.7%\u003c/p\u003e\n\u003cp\u003eCervical 29.4%\u003c/p\u003e\n\u003cp\u003eEndometrial 13.3%\u003c/p\u003e\n\u003cp\u003eTrophoblastic 5.4%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eEORTC QLQ-SWB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.468\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eDamen (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNetherlands \u003c/strong\u003e\u003cstrong\u003e[30]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e400\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eSecondary Analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 52%\u003c/p\u003e\n\u003cp\u003eFemale 48%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eProtestant or Catholic not church going 41%\u003c/p\u003e\n\u003cp\u003eProtestant or Catholic church going 19%\u003c/p\u003e\n\u003cp\u003eOther 40%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.43\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eDaugherty (2005)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[43]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e162\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eGI 49%\u003c/p\u003e\n\u003cp\u003eLung 34%\u003c/p\u003e\n\u003cp\u003eGYN/Urinary 20%\u003c/p\u003e\n\u003cp\u003eHead and Neck 2%\u003c/p\u003e\n\u003cp\u003eOther 18%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 55%\u003c/p\u003e\n\u003cp\u003eFemale 45%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eCatholic 53%\u003c/p\u003e\n\u003cp\u003eProtestant 35%\u003c/p\u003e\n\u003cp\u003eJewish 3%\u003c/p\u003e\n\u003cp\u003eOther 2%\u003c/p\u003e\n\u003cp\u003eNone 8%\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.36\u003c/p\u003e\n\u003cp\u003e(0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eDel Giglio (2006)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBrazil \u003c/strong\u003e\u003cstrong\u003e[46]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 36.1%\u003c/p\u003e\n\u003cp\u003eFemale 63.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003cp\u003e(0.025)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eFrost (2013)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[44]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e1578\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLung 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eSecondary Analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 52.1%\u003c/p\u003e\n\u003cp\u003eFemale 47.9%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eSF-8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.52\u003c/p\u003e\n\u003cp\u003e(not reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eHarbali (2022)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTurkey \u003c/strong\u003e\u003cstrong\u003e[31]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e406\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eLeukemia 27.8%\u003c/p\u003e\n\u003cp\u003eLymphoma 20.4%\u003c/p\u003e\n\u003cp\u003eLung 19.2%\u003c/p\u003e\n\u003cp\u003eBreast 8.4%\u003c/p\u003e\n\u003cp\u003eColon 4.9%\u003c/p\u003e\n\u003cp\u003ePancreas 4.2%\u003c/p\u003e\n\u003cp\u003eOther 15.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 56.9%\u003c/p\u003e\n\u003cp\u003eFemale 43.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eMuslim 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eSpiritual Orientation Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.193\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eHsieh (2020) and\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLee Y (2023)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States (Native American) \u003c/strong\u003e\u003cstrong\u003e[21, 22]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e73\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.58\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eKamijo (2018)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eJapan \u003c/strong\u003e\u003cstrong\u003e[27]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e176\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 38.6%\u003c/p\u003e\n\u003cp\u003eGyn 25.0%\u003c/p\u003e\n\u003cp\u003ePancreatic/liver/bile 15.3%\u003c/p\u003e\n\u003cp\u003eColorectal 9.7%\u003c/p\u003e\n\u003cp\u003eGastric 3.4%\u003c/p\u003e\n\u003cp\u003eLung 2.8%\u003c/p\u003e\n\u003cp\u003eUrological 0.6%\u003c/p\u003e\n\u003cp\u003eThyroid 0.6%\u003c/p\u003e\n\u003cp\u003eOther 4.0%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 25%\u003c/p\u003e\n\u003cp\u003eFemale 75%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.7146\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eKyranou (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCyprus \u003c/strong\u003e\u003cstrong\u003e[40]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e104\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 43%\u003c/p\u003e\n\u003cp\u003eFemale 57%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eEORTC QLQ-SWB\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.15\u003c/p\u003e\n\u003cp\u003e(Not Reported)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eLeak (2008)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[37]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eBaptist 50%\u003c/p\u003e\n\u003cp\u003ePentecostal 6.7%\u003c/p\u003e\n\u003cp\u003ePresbyterian 3.3%\u003c/p\u003e\n\u003cp\u003eMuslin 3.3%\u003c/p\u003e\n\u003cp\u003eMethodist 6.7%\u003c/p\u003e\n\u003cp\u003eAME Zion 3.3%\u003c/p\u003e\n\u003cp\u003eNo affiliation 3.3%\u003c/p\u003e\n\u003cp\u003eOther 23.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eSpiritual Perspective Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eQuality of Life Index\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.70\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eLee, M (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSouth Korea \u003c/strong\u003e\u003cstrong\u003e[32]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e132\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNon-Small Cell Lung 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 72%\u003c/p\u003e\n\u003cp\u003eFemale 28%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.39\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.0001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eMajda (2022)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePoland \u003c/strong\u003e\u003cstrong\u003e[33]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e101\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 45%\u003c/p\u003e\n\u003cp\u003eFemale 55%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eDaily Spiritual Experience Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eEORTC QLQ-C30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.516\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003ePahlevan Sharif (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMalaysia \u003c/strong\u003e\u003cstrong\u003e[34]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e145\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eMuslin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eBeliefs and Values Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eMcGIll\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.46\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003ePuspita (2023)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIndonesia \u003c/strong\u003e\u003cstrong\u003e[36]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e112\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eSF-36\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.817\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eRandazzo (2021)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUnited States \u003c/strong\u003e\u003cstrong\u003e[35]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e606\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eBreast 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-Sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eFemale 100%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eChristian 73.9%\u003c/p\u003e\n\u003cp\u003eUnknown 13.7%\u003c/p\u003e\n\u003cp\u003eNone 6.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.66\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.0001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eWhitford (2008)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAustralia \u003c/strong\u003e\u003cstrong\u003e[39]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e449\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eHead/Neck 10.7%\u003c/p\u003e\n\u003cp\u003eUrological 17.8%\u003c/p\u003e\n\u003cp\u003eBreast 26.3%\u003c/p\u003e\n\u003cp\u003eColorectal 10.5%\u003c/p\u003e\n\u003cp\u003eLung 13.1%\u003c/p\u003e\n\u003cp\u003eLymphoma 13.1%\u003c/p\u003e\n\u003cp\u003eGyn 2.9%\u003c/p\u003e\n\u003cp\u003eSarcoma 1.1%\u003c/p\u003e\n\u003cp\u003eUpper GI 4.0%\u003c/p\u003e\n\u003cp\u003eCNS 0.7%\u003c/p\u003e\n\u003cp\u003eMelanoma 4.5%\u003c/p\u003e\n\u003cp\u003eLeukemia 0.7%\u003c/p\u003e\n\u003cp\u003eUnknown 2.7%\u003c/p\u003e\n\u003cp\u003eOther 2.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eSecondary analysis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 51.9%\u003c/p\u003e\n\u003cp\u003eFemale 48.1%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eChristian 57.2%\u003c/p\u003e\n\u003cp\u003eJewish 0.2%\u003c/p\u003e\n\u003cp\u003eUnknown 15.9%\u003c/p\u003e\n\u003cp\u003eNone 17.2%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.59\u003c/p\u003e\n\u003cp\u003e(\u0026lt;0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"142\"\u003e\n\u003cp\u003e\u003cstrong\u003eYilmaz (2020)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTurkey \u003c/strong\u003e\u003cstrong\u003e[28]\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"66\"\u003e\n\u003cp\u003e150\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"138\"\u003e\n\u003cp\u003eGI 69.3%\u003c/p\u003e\n\u003cp\u003eBreast/Thyroid 30.7%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"71\"\u003e\n\u003cp\u003eCross-sectional\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"100\"\u003e\n\u003cp\u003eMale 38.7%\u003c/p\u003e\n\u003cp\u003eFemale 61.3%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"118\"\u003e\n\u003cp\u003eNot Reported\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"80\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"84\"\u003e\n\u003cp\u003eFACT-G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"96\"\u003e\n\u003cp\u003e0.619\u003c/p\u003e\n\u003cp\u003e(0.001)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eSpiritual Well-Being\u003c/h2\u003e\n\u003cp\u003eTo assess spiritual well-being, the Functional Assessment in Chronic Illness Therapy \u0026ndash; Spirituality Well-being (FACIT-SP) was used in the majority (68%) of included studies [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. For studies that used the FACIT-SP, summary spiritual well-being scores ranged from 25.7 (SD 10.0) [\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e] to 79.3 (SD 18.46) [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e]. The FACIT-SP general spiritual well-being scale scores range from 0 to 92, with 92 signifying higher levels of spiritual well-being. Three of the included articles that used the FACIT-SP for their measurement of spirituality did not report their overall mean spirituality score for their study population, however these studies were included based on their inclusion of a correlation coefficient for the relationship between spirituality and QOL [\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThree of the included studies used the European Organization for Research and Treatment of Cancer Spirituality Scale (EORTC-SP) [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. For the included studies that used the EORTC-SP, mean spirituality was 60.4 (SD 28.7) [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] and 72.48 (SD 34.99) [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e]. An overall mean for spiritual well-being was not provided for one study, however the items means ranged from 2.63 (SD 0.61) to 3.33 (0.99) on a Likert-type scale from 1 (not at all) to 4 (very much) [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e]. The EORTC-SP measures spirituality on a scale from 0 to 100, with 100 signifying a higher level of spirituality. One study used the Spirituality Perspective Scale [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. The Spirituality Perspective Scale measures general spiritual well-being on a scale of 0 to 6, with 6 being high spiritual well-being. In this study the general spiritual well-being mean was 5.65 (SD 0.55) [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. The Beliefs and Values Scale, a 10-item questionnaire, was also used once [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e], by Pahelvan Sharif (2021) as their measurement of spirituality. The mean spirituality of their sample was not reported. The Daily Spiritual Experience Scale, was used once [\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e]. It is a 15 question measure utilizing a modified, six-point Liker-typet scale [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e]. Cumulative scores range from 16 to 96, with higher number corresponding to higher spirituality [\u003cspan class=\"CitationRef\"\u003e47\u003c/span\u003e]. Using the Daily Spiritual Experience Scale, Majda (2022) reported a mean spirituality of 65.22 (SD 21.05). Brandao (2021) used the World Health Organization Quality of Life Spirituality, Religiousness and Personal Beliefs Scale (WHOQOL-SRPB) with a mean spirituality score of 17.76 (SD 1.84) [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. The WHOQOL-SRPB includes 32 Likert-style questions with a score between 0 and 20 with higher numbers signifying higher levels of spirituality [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. The Spiritual Orientation Scale is a 7-item Likert-type scale with a range from 0 to 108, with higher values corresponding to higher levels of spirituality [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]. Harbali (2022) found the mean spirituality of their sample using the Spiritual Orientation Scale to be 87.9 (SD 18.5). See Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e for complete breakdown of measurements of spirituality.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMeasurements of Spirituality included in Review\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eMeasure\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e# of items\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSubscales\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eValidated Languages\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eValidated Disease Population\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eValidated Religious Populations\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eReliability from original factor analysis\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEORTC-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eRelationship with others, Relationship with self, Relationship with something greater, Existential,\u003c/p\u003e\n\u003cp\u003eRelationship with God if applicable\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBengali, Chinese, Croatian, Dutch, English, Finnish, French, German, Greek, Icelandic, Italian, Japanese, Norwegian, Persian, Portuguese, Russian, Spanish, Slovak, Swahili, Swedish, and Vietnamese [\u003cspan class=\"CitationRef\"\u003e67\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCancer [\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbrahamic Religions [\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.7 [\u003cspan class=\"CitationRef\"\u003e68\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFACIT-SP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMeaning, Peace, and Faith along with general measurement of spirituality\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArabic, Bengali, Burmese, Chinese, Croatian, Czech, Danish, Dutch, English, Farsi, French, German, Greek, Hebrew, Hindi, Hungarian, Indonesian, Italian, Japanese, Korean, Lithuanian, Malay, Malayalam, Marathi, Nepali, Norwegian, Polish, Portuguese, Serbian, Sinhalese, Spanish, Slovak, Slovene, Swahili, Swedish, Tamil, Telugu, Thai, Turkish, and Vietnamese [\u003cspan class=\"CitationRef\"\u003e69\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCancer, HIV/AIDS [\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eDiabetes, Heart disease, Thyroid disease, Rheumatoid arthritis, COPD [\u003cspan class=\"CitationRef\"\u003e71\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eCystic fibrosis [\u003cspan class=\"CitationRef\"\u003e72\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eOrthopedic disease [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003ePsychiatric disorders [\u003cspan class=\"CitationRef\"\u003e74\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJudo-Christian[\u003cspan class=\"CitationRef\"\u003e75\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e76\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eBuddhism [\u003cspan class=\"CitationRef\"\u003e73\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eIslam [\u003cspan class=\"CitationRef\"\u003e77\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.88 [\u003cspan class=\"CitationRef\"\u003e70\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpirituality Perspective Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArabic [\u003cspan class=\"CitationRef\"\u003e78\u003c/span\u003e], Chinese [\u003cspan class=\"CitationRef\"\u003e79\u003c/span\u003e], English, Italian [\u003cspan class=\"CitationRef\"\u003e80\u003c/span\u003e], Korean [\u003cspan class=\"CitationRef\"\u003e81\u003c/span\u003e], Persian [\u003cspan class=\"CitationRef\"\u003e82\u003c/span\u003e], and Spanish [\u003cspan class=\"CitationRef\"\u003e83\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTerminally Ill [\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003eChronic Kidney disease [\u003cspan class=\"CitationRef\"\u003e85\u003c/span\u003e]\u003c/p\u003e\n\u003cp\u003ePregnancy [\u003cspan class=\"CitationRef\"\u003e86\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbrahamic Religions [\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.89 [\u003cspan class=\"CitationRef\"\u003e84\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBeliefs and Values Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArabic [\u003cspan class=\"CitationRef\"\u003e87\u003c/span\u003e] and English\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCancer\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAbrahamic Religions, Hinduism, and Buddhism\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.94 [\u003cspan class=\"CitationRef\"\u003e88\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDaily Spiritual Experience\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e16\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArabic, Czech, Danish, Dutch, English, Flemish, Filipino, French, Greek, Hebrew, Hungarian, Italian, Japanese, Korean, Latvian, Lithuanian, Malay, Malayalam, Nepalese, Persian, Polish, Romanian, Russian, Serbian, Slovenian, Thai, Turkish, Ukrainian, Urdu, and Vietnamese [\u003cspan class=\"CitationRef\"\u003e89\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eJudo-Christian [\u003cspan class=\"CitationRef\"\u003e90\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.9 [\u003cspan class=\"CitationRef\"\u003e90\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWHOQOL\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e32\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eArabic, Chinese, Croatian, Czech, Danish, Dari, Dutch, English, French, German, Hindi, Hungarian, Italian, Japanese, Kiswahili, Korean, Lithuanian, Norwegian, Polish, Portuguese, Russian, Serbian, Sinhala, Spanish, Swedish, and Turkish [\u003cspan class=\"CitationRef\"\u003e91\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNot specified\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.85 [\u003cspan class=\"CitationRef\"\u003e92\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpiritual Orientation Scale\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTurkish [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eUnknown\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.87 [\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eQuality of Life\u003c/h2\u003e\n\u003cp\u003eThe Functional Assessment of Cancer Treatment \u0026ndash; General (FACT-G) was the most commonly used measurement of overall QOL (n\u0026thinsp;=\u0026thinsp;11, 48%) [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. The European Organization for Research and Treatment of Cancer Comprehensive Quality of Life (EORTC \u0026ndash; QOL- C30) was used in eight studies (32%) [\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. The EORTC-QOL-C30 summary of QOL score ranges from 0 to 100 with 100 signifying a higher QOL. In this review, EORTC-QOL-C30 study summary QOL score ranged from 45.2 (SD 24.0) [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] to 78.86 (SD 18.56) [\u003cspan class=\"CitationRef\"\u003e41\u003c/span\u003e]. The Short Form 8 (SF-8) [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e] and Short Form 36 (SF-36) were each used in a single study. The SF-8 and SF-36 both have a range from 0 to 100, with 100 signifying higher QOL. For the article included in this review, the mean QOL score on the SF-8 was 80 [\u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e], the QOL mean for the SF-36 [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] was not reported in study results. One study each used the McGill Scale [\u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e], and Quality of Life Index [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e]. For the Quality of Life Index, a range of 0 to 30 with 30 signifying higher quality of life, was used in a single study with a mean QOL of 26.6 (SD 2.92) [\u003cspan class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e\n\u003cp\u003eThe FACT-G is a commonly used QOL measurement tool designed specifically for use in the cancer population [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. It includes 27 Likert-style questions and has subscales of physical, social, emotional, and function well-being. It is an international measure having been validated and translated into 74 languages [\u003cspan class=\"CitationRef\"\u003e49\u003c/span\u003e]. Original psychometric testing of the FACT-G had good internal reliability [\u003cspan class=\"CitationRef\"\u003e50\u003c/span\u003e]. The EORTC-QLQ-C30 was the second most commonly used measurement tool for QOL in the articles included in this review. The EORTC-QLQ-C30 is another well-established, reliable and valid QOL measure specifically designed for the cancer population [\u003cspan class=\"CitationRef\"\u003e48\u003c/span\u003e]. The EORTC-QLQ-C30 has been translated and validated in 117 international languages. In addition to a general subscale of global health/QOL, the EORT-QLQ-C30 includes five functional subscales of physical, role, emotional, cognitive, and social. This QOL measurement tool also includes nine symptom subscales of fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial difficulties [\u003cspan class=\"CitationRef\"\u003e51\u003c/span\u003e].The SF 8 is a shorten form of the SF 36, both of these measure are highly established measurements of QOL in varying setting of disease and health. Similar to the two QOL measure previously discussed, the SF 8 and SF 36 are international measures that have been validated in over 50 languages in over 25 countries. Both the SF 8 and SF 36 have eight subscales including physical functioning, social functioning, role limitations physical, general medical health, mental health, role limitations emotional, vitality, and bodily pain address the psychological domain, and only 15% (n\u0026thinsp;=\u0026thinsp;11) address the social domain (remaining 10% (n\u0026thinsp;=\u0026thinsp;7) address global QOL) [\u003cspan class=\"CitationRef\"\u003e52\u003c/span\u003e]. Although less commonly used than the previously discussed measurement tools of QOL, the McGill scale and the Quality of Life Index are both well-established tools to measure QOL. The McGill scale was designed to examine QOL in adults facing a life-limiting illness, specifically adults with cancer or HIV/AIDS. The McGill scale is a 14 item questionnaire with four subscales including physical functioning, existential, social, and psychological [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]. Internal reliability for the McGill scale is 0.94 [\u003cspan class=\"CitationRef\"\u003e53\u003c/span\u003e]. In addition to English, the McGill scale has been validated in Arabic [\u003cspan class=\"CitationRef\"\u003e54\u003c/span\u003e], Chinese [\u003cspan class=\"CitationRef\"\u003e55\u003c/span\u003e], Italian [\u003cspan class=\"CitationRef\"\u003e56\u003c/span\u003e], Korean [\u003cspan class=\"CitationRef\"\u003e57\u003c/span\u003e], and Spanish [\u003cspan class=\"CitationRef\"\u003e58\u003c/span\u003e]. The Quality of Life Index is a valid QOL measure with an internal reliability of 0.96 [\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e]. The Quality of Life Index is a five item questionnaire includes four subscales of health and function, psychological/spiritual, social and economic, and family [\u003cspan class=\"CitationRef\"\u003e59\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003ch2\u003eSpirituality and QOL Subscales\u003c/h2\u003e\n\u003cp\u003eThirteen of the included articles included correlations associated with the measurement subscales of QOL in addition to reporting the overall correlation between spirituality and QOL [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e38\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Seven of these studies examined QOL using the FACT-G [\u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Five utilized the EORTC-QLQ-C30 as their QOL measurement [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e]. Frost et al. (2013) used the SF-8 as their measurement of QOL. Of the 13 articles that included measurement subscales of QOL in their analysis, eight also included subscales of their spirituality measurement in their correlation analysis [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e]. Of these eight articles, six examined spirituality through the FACIT-SP [\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e45\u003c/span\u003e] and two through the EORTC-QLQ-SWB [\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\n\u003ch2\u003eMeta-Analysis\u003c/h2\u003e\n\u003cdiv id=\"Sec9\" class=\"Section4\"\u003e\n\u003ch2\u003eCorrelation of Spiritual Well-Being and Quality of Life\u003c/h2\u003e\n\u003cp\u003eCorrelations (r) between QOL and spirituality ranged from 0.817 [\u003cspan class=\"CitationRef\"\u003e36\u003c/span\u003e] to 0.15 [\u003cspan class=\"CitationRef\"\u003e40\u003c/span\u003e] in the included studies. One study was an abstract only and did not report the correlation, however the p-value was given as 0.025 [\u003cspan class=\"CitationRef\"\u003e46\u003c/span\u003e]. All correlations were positive and statistically significant with a p-values of less than 0.05. These positive correlations signify that with higher spirituality, QOL was also higher. It is important to note that these results do not signify a causal relationship due to the limitations of correlations. Kyronou et al. (2021), Harbali et al. (2022), Chaar et al. (2018), Daugherty et al. (2005), Brandao et al. (2021), Asgeirdottir et al. (2017) and Lee et al. (2021) all found a definite, but small, positive correlations based on r\u0026rsquo;s of 0.15, 0.193, 0.271, 0.36, 0.372, 0.386 and 0.39 respectively [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. Eleven included articles had a moderate correlation with a substantial relationship with r\u0026rsquo;s between 0.43 and 0.67 [\u003cspan class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. The remaining articles included in this review, Leak et al. (2008), Kamijo et al. (2018), Bai et al. (2015 and 2018), and Puspita et al. (2023) had high correlations between spirituality and QOL with values of 0.7, 0.715, 0.74, 0.80, and 0.817 respectfully [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e]. The cumulative effect size demonstrated a moderate, substantial relationship between spirituality and QOL in cancer survivors (CES\u0026thinsp;=\u0026thinsp;0.527; CI 0.463, 0.591; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) [\u003cspan class=\"CitationRef\"\u003e60\u003c/span\u003e].\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section3\"\u003e\n\u003ch2\u003eCorrelation of Spiritual Well-Being and Quality of Life Subscales\u003c/h2\u003e\n\u003cdiv id=\"Sec11\" class=\"Section4\"\u003e\n\u003ch2\u003eQOL Subscales\u003c/h2\u003e\n\u003cp\u003eThe measurement domains of QOL included a combination of those of the FACT-G and the EORTC-QOL-C30, namely: physical health, social health, functional health, and emotional health. Frost (2013) did not include the domains of function or emotional health in their analysis. A small but definite relationship was found between physical health and spirituality (CES\u0026thinsp;=\u0026thinsp;0.242; CI 0.191, 0.293; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) along with social health and spirituality (CES\u0026thinsp;=\u0026thinsp;0.323; CI 0.259, 0.388; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). A substantial relationship was found between functional health and spirituality (CES\u0026thinsp;=\u0026thinsp;0.444; CI 0.306, 0.582; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e) along with emotional health and spirituality (CES\u0026thinsp;=\u0026thinsp;0.437; CI 0.389, 0.486; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003eSpirituality Subscales\u003c/h2\u003e\n\u003cp\u003eFor this meta-analysis, only the spirituality subscales of the FACIT-SP are reported here due to the EORTC-QLQ-SWB being used in only two articles. As previously mentioned, the FACIT-SP includes three subscales: meaning, peace, and faith. A substantial relationship was found between meaning and overall QOL (CES\u0026thinsp;=\u0026thinsp;0.599; CI 0.557, 0.642; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and peace and overall QOL (CES\u0026thinsp;=\u0026thinsp;0.614; CI 0.572, 0.656; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Faith and overall QOL were found to have a small, but significant relationship (CES\u0026thinsp;=\u0026thinsp;0.279; CI 0.228, 0.329; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Substantial relationships were also found between meaning and emotional well-being (CES\u0026thinsp;=\u0026thinsp;0.414; CI 0.365, 0.463; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) along with peace and emotional well-being (CES\u0026thinsp;=\u0026thinsp;0.485; CI 0.438, 0.532; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e for the cumulative effect sizes for the subscales of spirituality and QOL.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCumulative effect sizes and confidence intervals for spirituality and QOL subscales\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePhysical Well-Being\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eEmotional Well-Being\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eSocial Well-Being\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMeaning\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.314 (0.263, 0.365\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.414 (0.365, 0.463)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.365 (0.315, 0.414)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePeace\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.320 (0.269, 0.371)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.485 (0.438, 0.532)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.374 (0.325, 0.424)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFaith\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.151 (0.099, 0.204)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.219 (0.167, 0.271)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e0.176 (0.124, 0.229)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\"\u003eNote: all results had a p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review and meta-analysis found evidence of a significant, positive correlation between spirituality and QOL in cancer survivors. All of the included studies found a positive correlation between spirituality and QOL to be statistically significant, and a significant, moderate relationship based on the cumulative effect size. The results of this review indicate that it may be possible to improve the QOL of cancer survivors by improving their spirituality. A similar systematic review examining the relationship between spirituality and QOL in cardiovascular disease found slightly different results than those of cancer survivors, with approximately half of the studies included in the review of cardiovascular disease reporting negative or null correlations between spirituality and QOL in adults with cardiovascular disease [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Previous cancer research has found that despite significant advances in cancer diagnosis and treatment, the very diagnosis of cancer continues to result in \u0026ldquo;existential plight\u0026rdquo; or a specific search for meaning following the diagnosis of cancer [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. The difference in these two reviews may be due to a diagnosis of cancer resulting in an influx of thoughts concerning one\u0026rsquo;s own potential for existence or nonexistence that is not seen in other, similar life limiting, medical diagnoses such as cardiovascular disease [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. The phenomena of \u0026ldquo;existential plight\u0026rdquo; may aid in explaining the difference between these two reviews and aid in better understanding the relationship between spirituality and QOL in cancer survivorship.\u003c/p\u003e \u003cp\u003eOur findings suggest a positive correlation between increased levels of spirituality and QOL among cancer survivors. Future research is needed to improve the understanding of this relationship and its mediators so that supportive oncologic interventions can be modified to address unmet needs and spiritual suffering. Previous research has shown that increased spirituality is a significant coping mechanism that provides protection against depression [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e]. Although not addressed in this review, it is possible that this effect may be stronger in cancer survivor facing a high mortality cancer due to the increased potential for death from the disease resulting in increased introspection and life evaluation [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. More research is needed to examine the relationship between spirituality and QOL based on disease severity and/or stage of disease.\u003c/p\u003e \u003cp\u003eThe positive and statistically significant correlation between the domains of QOL and spirituality further demonstrates the positive relationship between these two variables. It is important to note that all of the relationships between the measurement domains and spirituality were weaker than the relationship between overall QOL and spirituality. These results may help us better understand the intricacies of the relationship between QOL of spirituality. Results demonstrated that the weakest relationship was between physical health and spirituality while the strongest relationship was between emotional heath and spirituality. Although more research is needed, this may provide insight into using and intervening on spirituality in order to impact and improve QOL, especially when taking into consideration the potential protective effects of spirituality on depression discussed previously.\u003c/p\u003e \u003cp\u003eCurrently, the cancer survivor literature lacks a standard measurement tool(s) for the evaluation of spirituality in cancer survivorship. One reason for this may be the variability of spirituality measurement tools and lack of a concise definition of spirituality in the current literature. Although spirituality measurement tools have been translated and had those translations validated in a wide variety of languages, the original factor analysis and measurement designs were done in limited populations. Only a single measurement of spirituality contained an international population in their study development with the WHOQOL-SRPB including study participants from every inhabited continent in their measurement design and factor analysis validation studies. However, the WHOQOL combines the concepts of spirituality, religious and person beliefs in their measurement scale. With spirituality and religiosity being two separate, yet related concepts this combination may be a barrier separating the concepts of spirituality and religiosity in cancer survivor research. Of the spirituality measurement tools in the review, those that reported religious affiliation of study participants for the primary validation studies, religious affiliation was almost exclusively that of Abrahamic religions (Christianity, Islam, and Judaism). There is a need for a spirituality measure tool that crosses all national borders and religious affiliations in order to truly understand and examine spirituality in the cancer survivorship population. As previously discussed, better understanding spirituality may be a key component in order to truly understand and examine QOL in cancer survivors.\u003c/p\u003e \u003cp\u003eThe results of this meta-analysis suggest that meaning and peace are the strongest aspects of spirituality that positively impact QOL, however a limitation to this finding is the subscales of spirituality study measurements. As previously mentioned, the core concept of spirituality are transcendence, meaningfulness and purposefulness, faithfulness, harmonious interconnectedness, holistic being, and integrative energy. Of the seven measurement tools of spirituality, only two included scoring for subscales (FACIT-SP and EORTC-QLQ-SWB. The subscales of the EORTC-QLQ-SWB focused on the relationship aspect of spirituality with relationship to self, others, and something greater than oneself as the key subscales. However, these subscales do not capture key concepts of spirituality such as meaningfulness and purposefulness. However, though the FACIT-SP subscales include meaning and peace, it does not examine the relationship aspect of spirituality found in the EORTC-QLQ-SWB. More research is needed into the subscale of spirituality in order to more completely understand their relationship to QOL. Additional research may also be needed into instrument development around spirituality in order to more accurately measure the concepts of spirituality in cancer survivorship.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eClinical Implications\u003c/h2\u003e \u003cp\u003eDespite the demonstrated relationship between spirituality and QOL, cancer survivors have reported that their healthcare providers discuss spirituality and spiritual well-being infrequently with them [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e]. A study of providers and adults with advanced illnesses found that providers frequently \u0026lsquo;miss the moment\u0026rsquo; to address spirituality and spiritual well-being with patients due to feeling that spiritual care is not something that the health care provider, could provide [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Additionally, an international qualitative study found that a key research priority for adults with life-limiting diseases was spirituality and provider education regarding addressing patient spirituality [\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e]. It is clear that spirituality plays a key and important role in cancer survivors QOL, yet the results of this review demonstrate the need to better understand the role that spirituality has in QOL including the different multidimensional concepts of spirituality.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis is the first systematic review to examine the relationship between spirituality and QOL in cancer survivors. However, there are several limitations of this review. We excluded non-English articles, potentially leading to publication bias. Another limitation is the heterogeneity of the types of cancers included in the reviewed studies. QOL and survivability in cancer can vary extensively between cancer types, even within the same cancer type due to stage of disease. Due to that, we were unable to determine if there is a relationship between cancer types and the correlation between spirituality and QOL, further studies are needed to examine these relationships further. Lastly, though there is strong evidence of a correlation between spirituality and QOL in cancer survivorship, our results do not address potential moderators or mediators to the relationship impacting spirituality and QOL. Again, more research is needed to address and examine potential moderators and mediators that potentially impact the relationship between spirituality and QOL.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the results of this review demonstrate the association between spirituality and QOL. Further research is needed in order to have a more complete and in-depth understanding of this relationship and the impact on this relationship for cancer survivors. By addressing spirituality, we, as healthcare providers may move towards supporting cancer survivors to experience and live at the highest level of QOL possible.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis work was supported by the Innovation Grant from the School of Nursing at Oregon Health \u0026amp; Science University.\u003c/p\u003e\n\u003cp\u003eNone of the authors have any conflict of interest to report or disclose.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. The first draft of the manuscript was written by Jenny Firkins and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eThe dataset generated as part of this review and meta-analysis are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. The first draft of the manuscript was written by Jenny Firkins and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel, R.L., et al., \u003cem\u003eCancer statistics, 2023\u003c/em\u003e. CA Cancer J Clin, 2023. 73(1): p. 17\u0026ndash;48.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSung, H., et al., \u003cem\u003eGlobal Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries\u003c/em\u003e. CA Cancer J Clin, 2021. 71(3): p. 209\u0026ndash;249.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBrown, A.J., et al., \u003cem\u003eNothing left to chance? The impact of locus of control on physical and mental quality of life in terminal cancer patients\u003c/em\u003e. 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Annals of behavioral medicine, 2002. 24(1): p. 22\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e, W.H.O. \u003cem\u003eWHOQOL: Measuring Quality of Lift\u003c/em\u003e. 2024; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.who.int/tools/whoqol/whoqol-100\u003c/span\u003e\u003cspan address=\"https://www.who.int/tools/whoqol/whoqol-100\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGroup, T.W., \u003cem\u003eThe World Health Organization quality of life assessment (WHOQOL): Development and general psychometric properties.\u003c/em\u003e Social science \u0026amp; medicine (1982), 1998. 46(12): p. 1569\u0026ndash;1585.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStatements \u0026amp; Declarations\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThis work was supported by the Innovation Grant from the School of Nursing at Oregon Health \u0026amp; Science University.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNone of the authors have any conflict of interest to report or disclose.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAll authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. The first draft of the manuscript was written by Jenny Firkins and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe dataset generated as part of this review and meta-analysis are available from the corresponding author on reasonable request.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cancer, health-related quality of life, oncology, quality of life, spirituality, meta-analysis, and systematic review","lastPublishedDoi":"10.21203/rs.3.rs-3911625/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3911625/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCancer is a leading cause of morbidity and mortality worldwide. Although people are living longer with cancer, cancer has the potential to negatively impact survivors’ quality-of-life (QOL). Spirituality encompasses the concepts of transcendence, meaningfulness, faith, connectedness, and integrative energy. Spirituality is a part of everyday existence across cultures and religions and is a part of the human experience. Yet little has been published on spirituality in cancer survivorship. We were unable to find any previous reviews that examined the literature on the potential relationship between QOL and spirituality in cancer survivorship. Thus the aim of this systematic review and meta-analysis is to examine the current literature to more fully understand the relationship between spirituality and QOL.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing PRISMA guidelines, a systematic review and meta-analysis were conducted to examine the relationship between spirituality and QOL in cancer survivorship in studies sourced from PubMed, CINHAL, and PsycINFO databases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty-four articles, published between 2005 and 2023 were included for review. All studies included demonstrated a significant, positive correlation between QOL and spirituality with r values ranging from 0.15 to 0.817.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings suggest a positive correlation between higher spirituality and increased QOL among cancer survivors. Future research is needed to improve the understanding of this relationship and its mediators so that supportive oncologic interventions can be modified to address unmet needs and spiritual suffering. By better understanding the relationship between spirituality and QOL, we can move towards supporting the highest level of QOL possible for cancer survivors.\u003c/p\u003e","manuscriptTitle":"Association of spirituality and quality of life in cancer survivors: A systematic review and meta- analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-16 04:18:37","doi":"10.21203/rs.3.rs-3911625/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-12-31T04:05:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-04-18T01:31:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"d0129d54-9cc1-4543-8417-86935c54a8fc","date":"2024-03-27T15:53:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-03-12T02:23:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-11T19:42:22+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-14T10:25:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Supportive Care in Cancer","date":"2024-01-30T19:55:30+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"supportive-care-in-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jscc","sideBox":"Learn more about [Supportive Care in Cancer](https://www.springer.com/journal/520)","snPcode":"520","submissionUrl":"https://submission.nature.com/new-submission/520/3","title":"Supportive Care in Cancer","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"856f6f94-27e3-4f03-baff-cfba3bdc3a9d","owner":[],"postedDate":"February 16th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-10T19:58:30+00:00","versionOfRecord":{"articleIdentity":"rs-3911625","link":"https://doi.org/10.1007/s00520-025-09306-y","journal":{"identity":"supportive-care-in-cancer","isVorOnly":false,"title":"Supportive Care in Cancer"},"publishedOn":"2025-03-04 15:57:55","publishedOnDateReadable":"March 4th, 2025"},"versionCreatedAt":"2024-02-16 04:18:37","video":"","vorDoi":"10.1007/s00520-025-09306-y","vorDoiUrl":"https://doi.org/10.1007/s00520-025-09306-y","workflowStages":[]},"version":"v1","identity":"rs-3911625","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3911625","identity":"rs-3911625","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}