Spiritual well-being, faith, meaning in life, peace, and purpose in life for cancer-related fatigue: systematic review with meta-analysis and meta-regressions

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ Esta es la versión aceptada del artículo publicado en: This is a accepted manuscript of a paper published in: Journal of Cancer Survivorship (2023) DOI: https://doi.org/10.1007/s11764-024-01579-2 Copyright: © 2024. The Author(s), under exclusive licence to Springer Science +Business Media, LLC, part of Springer Nature. El acceso a la versión publicada del artículo puede requerir la suscripción de la revista. Access to the published version may require subscription. “This version of the article has been accepted for publication, after peer review (when applicable) and is subject to Springer Nature’s AM terms of use, but is not the Version of Record and does not reflect post-acceptance improvements, or any corrections. The Version of Record is available online at: https://doi.org/10.1007/s11764-024-01579-2”. 1 SPIRITUAL WELL-BEING, FAITH, MEANING IN LIFE, PEACE, AND PURPOSE IN LIFE FOR CANCER-RELATED FATIGUE: SYSTEMATIC REVIEW WITH METAANALYSIS AND META-REGRESSIONS Javier Martinez-Calderon PhD a,b; Cristina García-Muñoz PhD b,c*; Francisco Javier Cano-García PhD d; Alberto Marcos Heredia-Rizo PhD a,b a Instituto de Biomedicina de Sevilla, IBiS, Departamento de Fisioterapia, Universidad de Sevilla, Sevilla, Spain. b CTS 1110: Understanding Movement and Self in health from Science (UMSS) Research Group, Andalusia, Spain. c Departamento de Ciencias de la Salud y Biomédicas. Universidad Loyola de Andalucía, Sevilla, Spain. d Departamento de Personalidad, Evaluación y Tratamiento Psicológicos, Universidad de Sevilla, 41018 Sevilla, Spain. RUNNING HEAD: spiritual well-being in cancer. Word count: 4,064 Figures: 3 Tables: 3 Supplementary files: 7 *Corresponding author: Universidad Loyola de Andalucía, Avda. de las Universidades s/n, 41704 Sevilla, Sevilla, Spain. Email address: [email protected] Author Contributions statement Conceptualization (JMC), Data Curation (JMC), Formal Analysis (JMC, FJCG, AMHR, and CGM), Funding Acquisition (not applicable), Investigation (not applicable), Methodology (all authors), Project Administration (JMC), Resources (not applicable), Software (CGM), Supervision (JMC), Validation (not applicable), Visualization (not applicable), Writing – Original Draft (JMC, FJCG, and AMHR), Writing – Review & Editing (all authors). Data availability statement No extra data are available. Funding statement This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Ethical approval statement This is a systematic review and thus, this statement is not applicable. Patient consent statement This is a systematic review and thus, this statement is not applicable. 2 Abstract Background: Cancer-related fatigue is associated with spiritual distress. Spiritual wellbeing, characterized by the presence of factors such as meaning in life or purpose in life, seems to play an important role in the management of symptoms of cancer. Currently, the number of studies evaluating the association between cancer-related fatigue and spiritual well-being is increasing and no systematic review has been conducted. Aim: To summarize the association between cancer-related fatigue and spiritual well-being, faith, meaning in life, peace, and purpose in life. Design: A systematic review with metaanalysis. Data sources: The CINAHL, Embase, PsycINFO, and PubMed databases were searched from inception to 9 October 2023. We considered studies evaluating the cross-sectional or longitudinal association between cancer-related fatigue and the spiritual factors above mentioned. The Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies and the Quality in Prognosis Studies tool assessed the methodological quality of cross-sectional and longitudinal studies, respectively. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system rated the certainty of evidence. Meta-analyses, meta-regressions, subgroup meta-analyses, and sensitivity analyses were conducted. Results: A total of 13 studies were included and no longitudinal findings were found. One meta-analysis showed that cancer-related fatigue may be negatively correlated with spiritual well-being (r= -0.37 (95%CI -0.44 to -0.28) p<0.01). In addition, another meta-analysis found the correlation between cancer-related fatigue and faith was not statistically significant (r= -0.25 (95%CI -0.66 to 0.28) p=0.36). Conclusions: Cancer-related fatigue may be correlated with spiritual well-being. However, the certainty of evidence was very low across the metaanalyzed outcomes. Funding: none. Review protocol: https://doi.org/10.17605/OSF.IO/2PB7X Keywords: Cancer; cancer-related fatigue; meta-analysis; review; spirituality. What is already known about the topic? •The number of studies evaluating spiritual factors and cancer-related fatigue is increasing. What this paper adds •This is the first systematic review with meta-analysis on this topic. Implications for practice, theory, or policy •A negative correlation was observed between spiritual well-being and cancerrelated fatigue. 3 Introduction The pathogenesis of cancer-related fatigue is complex, multidimensional, and not fully understood.1 The severity and persistence of fatigue in people with cancer are highly heterogeneous and may be associated with individual differences.2 In this sense, multiple biopsychosocial factors may influence how individuals with cancer manage their fatigue.3 In this context, evidence has shown that childhood adversity, history of depression, catastrophizing, sleep disturbance, loneliness, and trait anxiety may be possible risk factors for cancer-related fatigue.2 Current cancer care programs have underlined the importance of including spiritual care in the management of symptoms of cancer.4 Existential distress is an important dimension of cancer-related distress that needs specific attention.5 Important studies in the field of spirituality and cancer have shown spiritual needs are reported by patients with cancer.6–8 These spiritual needs are mainly based on the necessity of finding connection, peace, meaning and purpose, and transcendence.6–9 Spiritual needs may be even more important in people with terminal cancer, underlying the relevance of making sense of dying, living with dying, feeling connected, and being reflective.10 Some of these spiritual needs (e.g., meaning in life and faith) are included in the construct of spiritual well-being,11 which may be very important in the quality of life of people with cancer.12 Overall, spiritual well-being can be composed of perceived happiness, positive self-worth, and aspects related to acceptance, openness, and awareness, among other factors (e.g., meaning in life).13 In cancer, systematic reviews have found that spiritual well-being and some of its factors (meaning in life or purpose in life) may be associated with more perceived happiness,14 life satisfaction,14 posttraumatic growth,15 and acceptance of cancer.16 In the last two decades, the number of studies evaluating the role of spiritual well-being, meaning in life or purpose in life, peace, and faith in cancer-related fatigue has increased.17–20 However, no systematic reviews with meta-analysis have been conducted yet. Therefore, we aimed to conduct a systematic review with meta-analysis to summarize the possible cross-sectional and longitudinal associations between cancer-related fatigue and spiritual well-being, faith, meaning in life, peace, and purpose in life in people with cancer without sociodemographic (e.g., age or sex/gender) and clinical (e.g., cancer site or cancer stage) restrictions. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement and the PRISMA for abstracts were followed.21,22 The review protocol was prospectively registered at Open Science Framework (https://doi.org/10.17605/OSF.IO/2PB7X). 4 Deviations from the Review Protocol The research design was changed from a scoping review to a systematic review with meta-analysis. This allowed us to develop robust quantitative analyses (e.g., metaanalyses, subgroups meta-analyses, and meta-regressions) as well as evaluate the certainty of evidence of the meta-analyzed outcomes. In addition, faith and peace are aspects of spiritual well-being. Therefore, these factors were included in this review as outcome measures. This review was focused on observational studies. In addition, interventional studies were included if they reported baseline data regarding the association of interest. This decision was made to avoid misdirected conclusions. No manual searches were conducted. We have acknowledged this issue in the limitations section. Finally, the following analyses were conducted according to the guidelines to develop high-quality systematic reviews: methodological quality/risk of bias assessment, certainty of evidence, meta-analyses, sensitivity analyses, meta-regressions, and subgroup metaanalyses.21 Data Sources and Search Strategies One reviewer (JMC) searched for the CINAHL (via EBSCOhost), Embase, PsycINFO (via ProQuest), and PubMed databases potential studies from inception to 9 October 2023. Search filters were used for language and document type. Supplementary File 1 shows the full search strategy for each electronic database. Eligibility Criteria The PECOs (Population, Exposure, Comparator, Outcomes, Study design) framework was followed to build the eligibility criteria.23 Inclusion criteria: - Population: people with cancer without sociodemographic (e.g., age or sex/gender) and clinical (e.g., cancer site or cancer stage) restrictions. - Exposure: Spiritual well-being, faith, meaning in life, peace, and purpose in life. No restrictions were imposed regarding how these factors were measured (e.g., validated self-reported tools or a single question). The definitions of these factors appear in Table 1. - Comparators: Not applicable. - Outcomes: Cancer-related fatigue. No restrictions were imposed regarding how this factor was measured (e.g., validated self-reported tools or a single question). 5 - Study design: Observational studies (cross-sectional studies, cohort studies, case-control studies) and baseline data from clinical trials. Only studies published in peer-reviewed journals and written in English or Spanish languages were included. Exclusion criteria: - Cancer was not analyzed separately from other clinical or non-clinical populations. - Cluster analysis. - The instrument combined different constructs under the same concept. For example, we excluded those studies where the subdomain “meaning” of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale was used. This dimension combines items evaluating meaning in life (e.g., My life has been productive) and purpose in life (e.g., I feel a sense of purpose in my life). Therefore, the use of this dimension may cause misdirected conclusions. - Studies where peace was jointly analyzed with meaning. This was the case of studies that used the 2-factor model of the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale: (1) meaning/peace and (2) faith.11 - Analyses where cancer-related fatigue was used as an exposure and not as an outcome. - Analyses where spiritual well-being, faith, meaning in life, peace, or purpose in life were used as outcomes and not as exposures. - Analyses where beta coefficients, correlation coefficients, or odds ratios were not reported. - Impossibility of accessing at full text. - Protocols and conference abstracts/proceedings. Table 1. Definitions: Exposures included in this review. Concept Definition Spiritual wellbeing This construct may refer to individuals’ perception of well-being related to God and their sense of meaning, purpose, and satisfaction with life without references to religious issues.24–26 Spiritual well-being may include all constructs described below and imply transcendence.24 Spiritual well-being is not a synonym for spiritual health or spiritual maturity.24 6 Meaning in life The individual feels that everything occurs due to a greater plan or mission.27 This factor helps us understand that life circumstances are paths to personal growth.28 Purpose in life It may be the abstract expression of our meaning in life and can be conceptualized as the perception life is directed, organized, and motivated toward important personal, professional, and spiritual goals.29,30 It may include examples such as love, family, peace, or freedom.28 Peace This factor implies a state of inner calm where peace, harmony, and serenity can be related to God or a philosophy of life or value system.27 Faith The belief that something (e.g., value system) or someone (e.g., God) that is not scientifically provable may help in understanding and accepting everything happens for a reason, which can be useful for facing difficult situations.27 Study Selection One reviewer (JMC) conducted the study selection. This reviewer removed duplicates manually using Zotero Desktop version 6.0.30. Afterward, JMC read titles and abstracts, and subsequently, full texts were analyzed when abstracts seemed eligible or if abstracts were unavailable. Consensus between all authors was needed in seven studies.31–37 One author was contacted via email to clarify some information, and this author responded.36 Finally, this study was excluded.36 Supplementary File 2 shows the reasons for excluding studies during the analysis of full-text (k=53). Methodological Quality and Risk of Bias Assessment Two reviewers (AMHR and FJCG) independently used the Joanna Briggs Institute Checklist for Analytical Cross-Sectional Studies to assess the methodological quality of cross-sectional studies.38 This tool consists of 8 items that can be evaluated as ‘yes’, ‘no’, ‘unclear’, or ‘not applicable’. This tool does not have an overall score,38 and thus, the assessment of each item was presented for each included study. We considered cross-sectional studies those studies that reported only the association of interest at baseline, and no follow-up of interest was provided. Consensus was needed to solve some disagreements between AMHR and FJCG. The percentage of agreement between these reviewers was calculated considering the 7 number of items rated with the same score before pooling the results of the independent assessments. The inter-rater reliability percentage is shown in the results section. Finally, the use of the Quality in Prognosis Studies (QUIPS) tool was planned to evaluate the risk of bias in longitudinal studies.39 However, the QUIPS tool was not used since no longitudinal findings of interest were found. The Certainty of Evidence (GRADE) Two reviewers (CGM and JMC) independently used GRADE to rate the certainty of evidence.40 The criteria used by the GRADE system to downgrade the certainty of evidence are the presence of risk of bias, inconsistency of the results, indirectness of evidence, imprecision, and publication bias.40 This certainty can be downgraded to one or two levels depending on the presence of serious (-1 level) or very serious (-2 level) methodological concerns.40 The overall score that each outcome can reach is high, moderate, low, or very low evidence. In observational studies, the certainty of evidence begins as low evidence, but this certainty may be upgraded if any of the following requirements is reached: large effect sizes, dose-response gradient, or the consideration of all plausible confounding factors.40 The certainty of evidence was only rated to those outcomes that were meta-analyzed: (1) spiritual well-being and (2) faith. Data Extraction One reviewer (AMHR) extracted from the included studies the following information, when possible: first author and year of publication, number of participants, mean age, sex/gender, comorbidities, cancer sites (e.g., breast cancer), number of cancer sites, the cancer stage, the time since cancer diagnosis, pain assessment, chemotherapy or radiation therapy, religious affiliations, religion assessment, educational stages, income levels, race/ethnicity, exposures, outcomes, main findings. Data Analysis The main characteristics of the included studies are reported in Supplementary File 3. Additionally, two sections were developed in the main text to show the pooled association between cancer-related fatigue and: (1) spiritual well-being or (2) faith. Meta-analyses were conducted when at least two studies evaluated the association between the same exposure and outcome (e.g., spiritual well-being and cancer-related fatigue). These meta-analyses were depicted using forest plots. 8 When necessary, beta coefficients were transformed into correlation coefficients (r) before conducting the analysis. Beta coefficients were only transformed into correlation coefficients when their values ranged from -0.5 to 0.5.41 Afterward, data were pooled using a random effect model, and correlation coefficients were transformed using Fisher’s Z and subsequently, back transformed to correlation coefficients. The effect of a correlation coefficient can be interpreted as ‘low correlation’ (r= 0.10), ‘moderate correlation’ (r= 0.30), and ‘high correlation’ (r= 0.50).42 Meta-analyses were developed using R Studio software with the packages meta,43 metafor,44, and dmetar.45 Heterogeneity between studies was evaluated using the I2 test, considering a high heterogeneity when I2 > 50%. Heterogeneity between and within subgroups metaanalyses was also explored using the Tau2 test (heterogeneity if confidence intervals (95%CI) did not cross zero, 95%CI are only computed when at least three studies are evaluated)46 and the Q-test (heterogeneity if p<0.05).47 Prediction intervals Prediction intervals refer to the range of the predicted true effect in a new study, given the realized (past) studies.48,49 These intervals may help account for the heterogeneity and should be reported along with confidence intervals and the heterogeneity tests.50 Prediction intervals were depicted in the forest plots as a red line when sample sizes allowed it. Sensitivity analyses Sensitivity analyses were conducted to detect possible outliers or significant influential cases of the pooled effect size. These analyses were only developed when at least two studies were included in the meta-analysis. Sensitivity analyses included automatic outlier detection using dmetar, Baujat plot, doi plot, and leave-one-out analysis sorted by the effect size. When outliers were detected, they were removed from the meta-analysis. Subgroup meta-analyses Subgroups meta-analyses explored possible sources of heterogeneity. These analyses were only developed when at least two studies examined the same factor (e.g., a specific cancer site). 15 A concept analysis is also needed mainly considering the differences between meaning in life and purpose in life. This analysis is key before recommending cancer clinicians and researchers specific tools to evaluate these factors. Finally, we encourage researchers to include the most important sociodemographic and clinical characteristics of their participants. This is essential to extrapolate the results of cancer research into the clinical setting, but also this is key to authors of systematic reviews can perform more robust analyses. Limitations This systematic review was limited to summarizing the role of spiritual well-being, faith, meaning in life, peace, and purpose in life. Spiritual well-being, meaning in life, and purpose in life are probably the spiritual factors that most empirical attention has received in cancer research.14,15,67 In addition, spiritual well-being is commonly assessed in cancer patients using the Functional Assessment of Chronic Illness Therapy-Spiritual Well- Being Scale, which includes the dimensions of meaning, faith, and peace.11 This was the reason to focus this review on these factors. However, the readers should be aware that other spiritual factors (e.g., spiritual distress)68 may influence the experience of cancer and should be revised. Additionally, only studies published in peer-reviewed journals and written in English or Spanish language were considered. Manual searches were not conducted, and the search terms “harmony” or “serenity” were not searched, which are closely interrelated to peace. These decisions could affect the comprehensiveness of the review since some studies may have been missed. We encourage researchers to explore these limitations in future systematic reviews. Another important limitation was related to the methodological quality of the included studies. The tool that we used did not provide an overall score and thus, we could not include the results of this tool in our meta-regressions or subgroup meta-analyses. This caused us could not explore how the quality of studies may impact meta-analyzed results. We encourage researchers to use other tools with overall scores in future systematic reviews. These tools may offer a new insight into the role of risk of bias in meta-analyses. Furthermore, some included studies did not report important details about some clinical characteristics (e.g., the cancer stage). However, the corresponding authors were not contacted to request additional clinical details that may have strengthened our analyses. Finally, we would have loved to conduct separate analyses by participants with cancer and survivors of cancer. However, the use of the term “cancer survivors” remains a debate,69 this term was not clearly defined in some included studies that used it.51,53,54 In this context, we used the term people or participants with cancer throughout the 16 manuscript. We encourage the cancer community to develop a consensus to establish specific criteria to distinguish when an individual is considered a cancer survivor. This information may be helpful when making systematic reviews and primary research. Altogether, the limitations mentioned above may have affected the applicability of our results in clinical practice. However, we encourage the readers to use the results of this review as informative, as a first step to continue developing robust evidence in the field of spirituality and cancer-related fatigue. Conclusion To our knowledge, this is the first systematic review with meta-analysis that summarizes the cross-sectional and longitudinal associations between cancer-related fatigue and spiritual well-being, faith, meaning in life, peace, and purpose in life. Despite the higher levels of spiritual well-being may be correlated with lower levels of cancer-related fatigue, important methodological and clinical issues were discussed above. These methodological and clinical considerations may affect the certainty of evidence of the meta-analyzed outcomes, which was rated as very low. Declaration of conflicts of interest The authors declare that there is no conflict of interest. Legends Table 1. Definitions: Exposures included in this review. Table 2. Subgroup meta-analyses. Table 3. Univariate meta-regression analyses. Figure 1. The PRISMA 2020 flow diagram. Figure 2. Forest plot: spiritual well-being and cancer-related fatigue. Figure 3. Forest plot: faith and cancer-related fatigue. 17 References 1. O’Higgins CM, Brady B, O’Connor B, et al. The pathophysiology of cancer-related fatigue: current controversies. Support Care Cancer Off J Multinatl Assoc Support Care Cancer 2018; 26: 3353–3364. 2. Bower JE. The role of neuro-immune interactions in cancer-related fatigue: Biobehavioral risk factors and mechanisms. Cancer 2019; 125: 353–364. 3. Sleight AG, Crowder SL, Skarbinski J, et al. A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care. Cancers; 14. Epub ahead of print 14 April 2022. DOI: 10.3390/cancers14081982. 4. Ripamonti CI, Giuntoli F, Gonella S, et al. Spiritual care in cancer patients: a need or an option? Curr Opin Oncol 2018; 30: 212–218. 5. Vehling S, Philipp R. Existential distress and meaning-focused interventions in cancer survivorship. Curr Opin Support Palliat Care 2018; 12: 46–51. 6. Sastra L, Büssing A, Chen C-H, et al. Spiritual Needs and Influencing Factors of Indonesian Muslims With Cancer During Hospitalization. J Transcult Nurs Off J Transcult Nurs Soc 2021; 32: 212–220. 7. Riklikienė O, Tomkevičiūtė J, Spirgienė L, et al. Spiritual needs and their association with indicators of quality of life among non-terminally ill cancer patients: Cross-sectional survey. Eur J Oncol Nurs Off J Eur Oncol Nurs Soc 2020; 44: 101681. 8. Büssing A, Janko A, Baumann K, et al. Spiritual needs among patients with chronic pain diseases and cancer living in a secular society. Pain Med Malden Mass 2013; 14: 1362–1373. 9. Büssing A, Balzat H-J, Heusser P. Spiritual needs of patients with chronic pain diseases and cancer - validation of the spiritual needs questionnaire. Eur J Med Res 2010; 15: 266–273. 10. Hayden L, Byrne E, Deegan A, et al. A qualitative meta-synthesis examining spirituality as experienced by individuals living with terminal cancer. Health Psychol Open 2022; 9: 20551029221121526. 11. Peterman AH, Fitchett G, Brady MJ, et al. Measuring spiritual well-being in people with cancer: the functional assessment of chronic illness therapy--Spiritual Wellbeing Scale (FACIT-Sp). Ann Behav Med Publ Soc Behav Med 2002; 24: 49–58. 18 12. Jetan M, Daifallah A, Rabayaa MK, et al. The Impact of Spiritual Well-Being on the Quality of Life of Cancer Patients: A Cross-Sectional Study. Integr Cancer Ther 2023; 22: 15347354231210841. 13. Yang C-T, Yen S-Y, Chen J-O. [Spiritual well-being: a concept analysis]. Hu Li Za Zhi 2010; 57: 99–104. 14. Martinez-Calderon J, García-Muñoz C, Heredia-Rizo AM, et al. Meaning and purpose in life, happiness, and life satisfaction in cancer: Systematic review with meta-analysis. Psychooncology 2023; 32: 846–861. 15. Almeida M, Ramos C, Maciel L, et al. Meaning in life, meaning-making and posttraumatic growth in cancer patients: Systematic review and meta-analysis. Front Psychol 2022; 13: 995981. 16. Quinto RM, De Vincenzo F, Campitiello L, et al. Meaning in Life and the Acceptance of Cancer: A Systematic Review. Int J Environ Res Public Health; 19. Epub ahead of print 3 May 2022. DOI: 10.3390/ijerph19095547. 17. Lewis S, Salins N, Rao MR, et al. Spiritual well-being and its influence on fatigue in patients undergoing active cancer directed treatment: a correlational study. J Cancer Res Ther 2014; 10: 676–680. 18. Aukst-Margetić B, Jakovljević M, Ivanec D, et al. Religiosity and quality of life in breast cancer patients. Coll Antropol 2009; 33: 1265–1271. 19. Brandão ML, Fritsch TZ, Toebe TRP, et al. Association between spirituality and quality of life of women with breast cancer undergoing radiotherapy. Rev Esc Enferm U P 2021; 55: e20200476. 20. Chou Y-J, Lin H-Y, Cooper BA, et al. A Resilience Model for Patients With Colorectal Cancer: A Structural Equation Modeling Analysis. Cancer Nurs 2022; 45: E83–E90. 21. Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. 22. Beller EM, Glasziou PP, Altman DG, et al. PRISMA for Abstracts: reporting systematic reviews in journal and conference abstracts. PLoS Med 2013; 10: e1001419. 23. Morgan RL, Whaley P, Thayer KA, et al. Identifying the PECO: A framework for formulating good questions to explore the association of environmental and other exposures with health outcomes. Environ Int 2018; 121: 1027–1031. 24. Ellison, C. W. (1983). Spiritual Well-Being: Conceptualization and Measurement. Journal of Psychology and Theology, 11(4), 330-338. https://doi.org/10.1177/009164718301100406. 25. Blaikie NWH, Kelsen GP. Locating self and giving meaning to existence: A typology of paths to spiritual well-being based on new religious movements in Australia. In D. O. Moberg (Ed.), Spiritual well-being: Sociological perspectives. Washington, DC: University Press of America. 26. Moberg DO. Spiritual well-being. Washington, DC: University Press of America., 1979. 19 27. WHOQOL and Spirituality, Religiousness and Personal Beliefs (SRPB). Department of mental health. Social change and mental health cluster. World Health Organization. 1998. Available on: https://iris.who.int/bitstream/handle/10665/70897/WHO_MSA_MHP_98.2_eng.pdf ?sequence=1&isAllowed=y [Checked 09/01/2024]. 28. George LS, Park CL. Are meaning and purpose distinct? An examination of correlates and predictors. J Posit Psychol 2013; 8: 365–75. 29. Salsman JM, Schalet BD, Park CL, et al. Assessing meaning & purpose in life: development and validation of an item bank and short forms for the NIH PROMIS(®). Qual Life Res Int J Qual Life Asp Treat Care Rehabil 2020; 29: 2299–2310. 30. McKnight PE, Kashdan TB. Purpose in Life as a System that Creates and Sustains Health and Well-Being: An Integrative, Testable Theory. Rev Gen Psychol; 13(3):242-251. Epub ahead of print 2009. DOI: https://doi.org/10.1037/a0017152. 31. Gravier AL, Shamieh O, Paiva CE, et al. Meaning in life in patients with advanced cancer: a multinational study. Support Care Cancer 2020; 28: 3927–3934. 32. Hiratsuka Y, Suh S-Y, Kim S-H, et al. Factors related to spiritual well-being in the last days of life in three East Asian countries: An international multicenter prospective cohort study. Palliat Med 2021; 35: 1564–1577. 33. Miller M, Kwekkeboom K, Cherwin C. The role of spirituality in symptom experiences among adults with cancer. Support Care Cancer Off J Multinatl Assoc Support Care Cancer 2022; 30: 49–57. 34. Sherman AC, Simonton S, Latif U, et al. Religious struggle and religious comfort in response to illness: health outcomes among stem cell transplant patients. J Behav Med 2005; 28: 359–367. 35. Thompson P. The relationship of fatigue and meaning in life in breast cancer survivors. Oncol Nurs Forum 2007; 34: 653–660. 36. Visser A, Garssen B, Vingerhoets AJJM, et al. Existential Well-Being: Spirituality or Well-Being? J Nerv Ment Dis 2017; 205: 234–241. 37. Whitford HS, Olver IN, Peterson MJ. Spirituality as a core domain in the assessment of quality of life in oncology. Psychooncology 2008; 17: 1121–1128. 38. Moola S, Munn Z, Tufanaru C, Aromataris E, Sears K, Sfetcu R, Currie M, Qureshi R, Mattis P,, Lisy K, Mu P-F. Chapter 7: Systematic reviews of etiology and risk. In: Joanna Briggs Institute Reviewer’s Manual. In: Aromataris E, Munn Z (Editors)., https://jbi.global/sites/default/files/2019-05/JBI_Critical_Appraisal- Checklist_for_Analytical_Cross_Sectional_Studies2017_0.pdf (2017). 39. Hayden JA, van der Windt DA, Cartwright JL, et al. Assessing bias in studies of prognostic factors. Ann Intern Med 2013; 158: 280–286. 40. Schünemann H, Brożek J, Guyatt G, Oxman A, editors. GRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group, Available from guidelinedevelopment.org/handbook (2013). 20 41. Peterson RA, Brown SP. On the use of beta coefficients in meta-analysis. J Appl Psychol 2005; 90: 175–181. 42. Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd Edition. New York, NY: Routledge, 1988. 43. Balduzzi S, Rücker G, Schwarzer G. How to perform a meta-analysis with R: a practical tutorial. Evid Based Ment Health 2019; 22: 153–160. 44. Viechtbauer W. Conducting Meta-Analyses in R with the metafor Package. J Stat Softw 2010; 36: 1–48. 45. Harrer, M., Cuijpers, P., Furukawa, T. & Ebert DD dmetar. Companion R Package For The Guide “Doing Meta-Analysis in R”. R package version 0.0.9000., http://dmetar.protectlab.org/ (2019). 46. Borenstein, M., Hedges, L. V., Higgns, J. P. T., & Rothstein, H. R. (2009). Identifying and Quantifying Heterogeneity. En Introduction to Meta-Analysis (pp. 107-125). Wiley. ht tps://doi.org/10.1002/9780470743386.ch16. 47. Higgins JPT, Thomas J, Chandler J, Cumpston M, Li T, Page MJ, Welch VA (editors). Cochrane Handbook for Systematic Reviews of Interventions version 6.4 (updated August 2023). Cochrane, 2023. Available on: www.training.cochrane.org/handbook. [accessed 13/01/2024]. 48. Nagashima K, Noma H, Furukawa TA. Prediction intervals for random-effects meta-analysis: A confidence distribution approach. Stat Methods Med Res 2019; 28: 1689–1702. 49. Higgins JPT, Thompson SG, Spiegelhalter DJ. A re-evaluation of random-effects meta-analysis. J R Stat Soc Ser A Stat Soc 2009; 172: 137–159. 50. Riley RD, Higgins JPT, Deeks JJ. Interpretation of random effects meta-analyses. BMJ 2011; 342: d549. 51. Coleman D, Hurtado-de-Mendoza A, Montero A, et al. Stigma, social support, and spirituality: associations with symptoms among Black, Latina, and Chinese American cervical cancer survivors. J Cancer Surviv Res Pract. Epub ahead of print 22 November 2022. DOI: 10.1007/s11764-022-01283-z. 52. Grossoehme DH, Friebert S, Baker JN, et al. Association of Religious and Spiritual Factors With Patient-Reported Outcomes of Anxiety, Depressive Symptoms, Fatigue, and Pain Interference Among Adolescents and Young Adults With Cancer. JAMA Netw Open 2020; 3: e206696. 53. Jin J, Lee E, Lee S. Factors associated with distress among female cancer survivors at the workplace: A cross-sectional study. J Occup Health 2022; 64: e12364. 54. Jin J. Factors associated with the quality of work life among working breast cancer survivors. Asia-Pac J Oncol Nurs 2022; 9: 97–104. 55. Kandasamy A, Chaturvedi SK, Desai G. Spirituality, distress, depression, anxiety, and quality of life in patients with advanced cancer. Indian J Cancer 2011; 48: 55– 59. 21 56. Lee MK. Interactions of Spiritual Well-Being, Symptoms, and Quality of Life in Patients Undergoing Treatment for Non-Small Cell Lung Cancer: A Cross- Sectional Study. Semin Oncol Nurs 2021; 37: 151139. 57. Leeson LA, Nelson AM, Rathouz PJ, et al. Spirituality and the Recovery of Quality of Life Following Hematopoietic Stem Cell Transplantation. Health Psychol 2015; 34: 920–928. 58. Rabow MW, Knish SJ. Spiritual well-being among outpatients with cancer receiving concurrent oncologic and palliative care. Support Care Cancer 2015; 23: 919–923. 59. Yang Y, Zhao X, Cui M, et al. Dimensions of spiritual well-being in relation to physical and psychological symptoms: a cross-sectional study of advanced cancer patients admitted to a palliative care unit. BMC Palliat Care 2023; 22: 1–9. 60. Yellen SB, Cella DF, Webster K, et al. Measuring fatigue and other anemiarelated symptoms with the Functional Assessment of Cancer Therapy (FACT) measurement system. J Pain Symptom Manage 1997; 13: 63–74. 61. Okuyama T, Akechi T, Kugaya A, et al. Development and validation of the cancer fatigue scale: a brief, three-dimensional, self-rating scale for assessment of fatigue in cancer patients. J Pain Symptom Manage 2000; 19: 5–14. 62. Martinez-Calderon J, Casuso-Holgado MJ, Cano-García FJ, et al. Integrative model for self-perception of well-being in cancer. Disabil Rehabil 2023; 1–8. 63. Visser A, de Jager Meezenbroek EC, Garssen B. Does spirituality reduce the impact of somatic symptoms on distress in cancer patients? Cross-sectional and longitudinal findings. Soc Sci Med 2018; 214: 57–66. 64. de Jager Meezenbroek E, Garssen B, Van den Berg M, et al. Measuring spirituality as a universal human experience: development of the Spiritual Attitude and Involvement List (SAIL). J Psychosoc Oncol 2012; 30: 141–167. 65. A cross-cultural study of spirituality, religion, and personal beliefs as components of quality of life. Soc Sci Med 1982 2006; 62: 1486–1497. 66. Canada AL, Murphy PE, Fitchett G, et al. A 3-factor model for the FACIT-Sp. Psychooncology 2008; 17: 908–916. 67. McLouth LE, Ford CG, Pustejovsky JE, et al. A systematic review and metaanalysis of effects of psychosocial interventions on spiritual well-being in adults with cancer. Psychooncology 2021; 30: 147–158. 68. Martins H, Domingues TD, Caldeira S. Spiritual distress and religious involvement among cancer patients receiving chemotherapy: A longitudinal study. Int J Nurs Knowl. Epub ahead of print 27 August 2023. DOI: 10.1111/2047-3095.12442. 69. García-Vivar C. The Use and Misuse of the Concept of Cancer Survivor. Cancer Nurs 2022; 45: 419–420. 22 Table 1. Definitions: Exposures included in this review. Concept Definition Spiritual well-being This construct may refer to individuals’ perception of well-being related to God and their sense of meaning, purpose, and satisfaction with life without references to religious issues.24–26 Spiritual well-being may include all constructs described below and imply transcendence.24 Spiritual well-being is not a synonym to spiritual health or spiritual maturity.24 Meaning in life The individual feels that everything occurs due to a greater plan or mission.27 This factor helps us understand that life circumstances are paths to personal growth.28 Purpose in life It may be the abstract expression of our meaning in life and can be conceptualized as the perception life is directed, organized, and motivated toward important personal, professional, and spiritual goals.29,30 It may include examples such as love, family, peace, or freedom.28 Peace This factor implies a state of inner calm where peace, harmony, and serenity can be related to God or a philosophy of life or value system.27 Faith The belief that something (e.g., value system) or someone (e.g., God) that is not scientifically provable may help in understanding and accepting everything happens for a reason, which can be useful for facing difficult situations.27 Table 2. Subgroup meta-analyses. Subgroup r (95% CI) I2 Q within subgroups (p-value)* Q Between groups (p-value)* Spiritual well-being – cancer-related fatigue (k=7) Breast cancer Yes (3) 17,54,55 NA (1) 59 No (3) 20,51,56 -0.22 (-0.36 to -0.08) -0.54 (-0.66 to -0.39) -0.34 (-0.45 to -0.21) 73.5% NA 0% 8.55 (p=0.07) 6.38 (p=0.04*) Cancer stages Stage 0 Yes (1) 20 NA (2) 55,59 No (4) 17,51,54,56 Stage I Yes (5) 17,20,51,54,56 NA (2) 55,59 Stage II Yes (5) 17,20,51,54,56 NA (2) 55,59 Stage III Yes (5) 17,20,51,54,56 NA (2) 55,59 Stage IV Yes (3) 17,51,56 NA (2) 55,59 No (2) 20,54 -0.33 (-0.52 to -0.10) -0.50 (-0.65 to -0.31) -0.25 (-0.38 to -0.12) -0.27 (-0.37 to -0.17) -0.50 (-0.64 to -0.32) -0.27 (-0.37 to -0.17) -0.50 (-0.64 to -0.32) -0.27 (-0.37 to -0.17) -0.50 (-0.64 to -0.32) -0.32 (-0.46 to -0.17) -0.50 (-0.65 to -0.31) -0.21 (-0.37 to -0.04) NA 0% 68.6% 66.2% 0% 66.2% 0% 66.2% 0% 0% 0% 89.5% 10.34 (p=0.03*) 12.64 (p=0.03*) 12.64 (p=0.03*) 12.64 (p=0.03*) 11.81 (p=0.02*) 4.3 (p=0.11) 4.67 (p=0.03*) 4.67 (p=0.03*) 4.67 (p=0.03*) 5.10 (p=0.08) Cervical cancer Yes (2) 17,51 NA (1) 59 No (4) 20,54–56 -0.34 (-0.50 to -0.14) -0.54 (-0.72 to -0.30) -0.27 (-0.39 to -0.13) 28.1% NA 73.1% 12.53 (p=0.01*) 3.86 (p=0.15) Chemotherapy Yes (4) 17,51,54,56 NA (3) 20,55,59 -0.25 (-0.39 to -0.11) -0.42 (-0.56 to -0.27) 68.6% 66.2% 15.47 (p=0.008*) 2.72 (p=0.10) Colorectal cancer Yes (1) 20 NA (1) 59 No (5) 17,51,54–56 -0.33 (-0.54 to -0.08) -0.54 (-0.72 to -0.29) -0.28 (-0.40 to -0.15) NA NA 64.8% 11.38 (p=0.02*) 3.41 (p=0.18) Elementary studies Yes (2) 51,59 NA (4) 17,20,55,56 No (1) 54 -0.48 (-0.58 to -0.36) -0.32 (-0.38 to -0.25) -0.06 (-0.21 to 0.09) 28.9% 0% NA 2.71 (p=0.61) 19.67 (p<0.001*) Gynecological cancer Yes (2) 17,55 NA (1) 59 No (4) 20,51,54,56 -0.33 (-0.5 to -0.12) -0.54 (-0.72 to -0.29) -0.28 (-0.40 to 0.14) 5.4% NA 74.7% 12.91 (p=0.01*) 3.56 (p=0.17) Head and neck cancer Yes (1) 17 NA (1) 59 No (5) 20,51,54–56 -0.28 (-0.52 to 0.04) -0.54 (-0.73 to -0.28) -0.29 (-0.41) to -0.16 NA NA 69.3% 13.04 (p=0.11) 3.16 (p=0.21) Figure 1. The PRISMA 2020 flow diagram. Records identified from Databases (n= 340) CINAHL (n= 75) Embase (n= 115) PsycINFO (n= 35) PubMed (n= 115) Records removed before screening Duplicate records manually removed: (n= 203) Records screened by title and abstract (n = 137) Records excluded by a human based on title/abstract (n = 71) Reports sought for retrieval (n = 66) Reports assessed for eligibility (n = 66) Reports excluded (n = 53) Cancer was jointly analyzed with other health conditions (n= 1) Impossibility of accessing at full text (n= 1) No association of interest (n= 24) No correlation or regression analyses between the exposure and the outcome of interest (n= 1) No exposure of interest (n= 14) No objective of this study (n= 3) No outcome of interest (n= 4) Qualitative research (n= 3) The instrument combined different constructs under the same concept (n= 2). Report included (n = 13) Identification of studies via databases Identification Screening Included Study Heterogeneity: Tau2 = 0.0212; Chi2 = 22.39, df = 6 (P < 0.01); I2 = 73% Prediction interval Test for overall effect: Z = −5.29 (P < 0.01) Chou et al. 2022 Coleman et al. 2022 Jin et al. 2022a Kandasamy et al. 2011 Lee 2021 Lewis et al. 2014 Yang et al. 2023 Total 1166 416 91 169 50 132 200 108 Weight 100.0% 17.8% 12.9% 15.4% 9.9% 14.5% 16.0% 13.6% IV, Random, 95% CI −0.33 [−0.44; −0.21] [−0.64; 0.07] −0.33 [−0.41; −0.24] −0.41 [−0.57; −0.22] −0.06 [−0.21; 0.09] −0.42 [−0.63; −0.16] −0.29 [−0.44; −0.13] −0.28 [−0.40; −0.14] −0.54 [−0.66; −0.39] Correlation −1 −0.5 0 0.5 1 Correlation IV, Random, 95% CI Study Heterogeneity: Tau2 = 1.6853; Chi2 = 532.72, df = 2 (P < 0.01); I2 = 100% Prediction interval Test for overall effect: Z = 0.64 (P = 0.52) Brandão et al. 2021 Leeson et al. 2015 Yang et al. 2023 Total 436 108 220 108 Weight 100.0% 33.3% 33.4% 33.3% IV, Random, 95% CI 0.45 [−0.76; 0.96] [−1.00; 1.00] 0.02 [−0.17; 0.21] 0.96 [ 0.95; 0.97] −0.49 [−0.62; −0.33] Correlation −1 −0.5 0 0.5 1 Correlation IV, Random, 95% CI Supplementary file 1. Search strategies. Electronic databases CINAHL via EBSCOhost (09/10/2023) (MH "Neoplasms+" OR AB (cancer* OR oncolo* OR metasta*)) AND AB (meaning-in- life OR meaningfulness OR purpose-in-life OR purpose-of-life OR life-purpose OR sense-of-purpose OR sense-of-life OR sense-of-coherence OR spiritual-well-being OR faith OR peace OR FACIT-sp OR Functional-Assessment-of-Chronic-Illness-Therapy- Spiritual-Well-Being) AND AB (fatigue) Cites retrieved= 75. Search modes - Boolean/Phrase Search filter by type of document: Academic Journal and Journals. Search filter by language: English and Spanish publications. EMBASE (09/10/2023) ('malignant neoplasm'/exp OR 'oncology'/exp OR 'metastasis'/exp OR cancer*:ab,ti OR metasta*:ab,ti OR oncolo*:ab,ti) AND ('meaning-in-life':ab,ti OR 'meaningfulness':ab,ti OR 'purpose in life':ab,ti OR 'purpose of life':ab,ti OR 'life purpose':ab,ti OR 'sense of purpose':ab,ti OR 'sense of life':ab,ti OR 'sense of coherence':ab,ti OR 'spiritual wellbeing':ab,ti OR faith:ab,ti OR peace:ab,ti OR 'FACIT-sp':ab,ti OR 'Functional- Assessment-of-Chronic-Illness-Therapy-Spiritual-Well-Being':ab,ti) AND (fatigue:ab,ti) Cites retrieved= 115. Search filter: publication type: Article AND Article in Press AND review. Search filter: language: English and Spanish publications. Note: The Embase database includes cites from the Medline database. PsycINFO (09/10/2023) ab((MAINSUBJECT.EXACT.EXPLODE "Neoplasms" OR (oncolo* OR cancer* OR metasta*)) ) AND ab((meaning-in-life OR meaningfulness OR purpose-in-life OR purpose-of-life OR life-purpose OR sense-of-purpose OR sense-of-life OR sense-of- coherence OR spiritual-well-being OR faith OR peace OR FACIT-sp OR Functional- Assessment-of-Chronic-Illness-Therapy-Spiritual-Well-Being) ) AND ab((fatigue) ) Cites retrieved= 35. Search filter by type of document: Scientific journals. Search filter by language: English and Spanish publications. PubMed (09/10/2023) (neoplasms [mh] OR oncolo* [tiab] OR cancer* [tiab] OR metasta* [tiab]) AND (meaning-in-life [tiab] OR meaningfulness [tiab] OR purpose-in-life [tiab] OR purpose- of-life [tiab] OR life-purpose [tiab] OR sense-of-purpose [tiab] OR sense-of-life [tiab] OR sense-of-coherence [tiab] OR spiritual-well-being [tiab] OR faith [tiab] OR peace [tiab] OR FACIT-sp [tiab] OR Functional-Assessment-of-Chronic-Illness-Therapy-Spiritual- Well-Being [tiab]) AND (fatigue [tiab]) Cites retrieved= 115. Search filter: Language: English and Spanish publications. Supplementary file 2. List of excluded studies that were reviewed in full text (k= 53): specific reasons. ➢ Cancer was jointly analyzed with other health conditions (n= 1) ➢ Impossibility of accessing at full text (n= 1) ➢ No association of interest (n= 24) ➢ No correlation or regression analyses between the exposure and the outcome of interest (n= 1) ➢ No exposure of interest (n= 14) ➢ No objective of this study (n= 3) ➢ No outcome of interest (n= 4) ➢ Qualitative research (n= 3) ➢ The instrument combined different constructs under the same concept (n= 2) Excluded reviews Reason 1. Albusoul RM, Hasanien AA, Abdalrahim MS, Zeilani RS, Al-Maharma DY. The effect of spiritual well-being on symptom experience in patients with cancer. Support Care Cancer. 2022 Aug;30(8):6767-6774. doi: 10.1007/s00520-022-07104-4. No association of interest. 2. Andrykowski MA, Bishop MM, Hahn EA, Cella DF, Beaumont JL, Brady MJ, Horowitz MM, Sobocinski KA, Rizzo JD, Wingard JR. Long-term health-related quality of life, growth, and spiritual well-being after hematopoietic stem-cell transplantation. J Clin Oncol. 2005 Jan 20;23(3):599-608. doi: 10.1200/JCO.2005.03.189. No association of interest. 3. Azam M, Aslam M, Basharat J, Mughal MA, Nadeem MS, Anwar F. An empirical study on quality of life and related factors of Pakistani breast cancer survivors. Sci Rep. 2021 Dec 22;11(1):24391. doi: 10.1038/s41598- 021-03696-9. No association of interest. 4. Benner C, Greenberg M, Shepard N, Meng MV, Rabow MW. The natural history of symptoms and distress in patients and families following cystectomy for treatment of muscle invasive bladder cancer. J Urol. 2014 Apr;191(4):937-42. doi: 10.1016/j.juro.2013.10.101. No objective of this study. Excluded reviews Reason 5. Bishop MM, Beaumont JL, Hahn EA, Cella D, Andrykowski MA, Brady MJ, Horowitz MM, Sobocinski KA, Rizzo JD, Wingard JR. Late effects of cancer and hematopoietic stem-cell transplantation on spouses or partners compared with survivors and survivor-matched controls. J Clin Oncol. 2007 Apr 10;25(11):1403-11. doi: 10.1200/JCO.2006.07.5705. No association of interest. 6. Borneman T, Piper BF, Koczywas M, Munevar CM, Sun V, Uman GC, Ferrell BR. A qualitative analysis of cancer-related fatigue in ambulatory oncology. Clin J Oncol Nurs. 2012 Feb;16(1):E26-32. doi: 10.1188/12.CJON.E26-E32. Qualitative research. 7. Borneman T, Sun V, Williams AC, Fujinami R, Del Ferraro C, Burhenn PS, Irish T, Zachariah F, van Zyl C, Buga S. Support for Patients and Family Caregivers in Lung Cancer: Educational Components of an Interdisciplinary Palliative Care Intervention. J Hosp Palliat Nurs. 2015 Aug;17(4):309-318. doi: 10.1097/NJH.0000000000000165. No association of interest. 8. Chin S, Cavadino A, Akroyd A, Tennant G, Dobson R, Gautier A, Reynolds L. An Investigation of Virtual Reality Nature Experiences in Patients With Metastatic Breast Cancer: Secondary Analysis of a Randomized Controlled Trial. JMIR Cancer. 2022 Jul 22;8(3):e38300. doi: 10.2196/38300. No association of interest. 9. Delgado-Guay MO, Palma A, Duarte E, Grez M, Tupper L, Liu DD, Bruera E. Association between Spirituality, Religiosity, Spiritual Pain, Symptom Distress, and Quality of Life among Latin American Patients with Advanced Cancer: A Multicenter Study. J Palliat Med. 2021 Nov;24(11):1606-1615. doi: 10.1089/jpm.2020.0776. No association of interest. 10. Dow KH, Ferrell BR, Leigh S, Ly J, Gulasekaram P. An evaluation of the quality of life among long-term survivors of breast cancer. Breast Cancer Res Treat. 1996;39(3):261-73. doi: 10.1007/BF01806154. No association of interest. Excluded reviews Reason 11. Ferrell BR, Grant M, Dean GE, Funk B, Ly J (1996) ``Bone tired'': The experience of fatigue and its impact on quality of life. Oncology Nursing Forum. 1996;23:1539-1547. Impossibility of accessing at full text. 12. Forsberg C, Björvell H, Cedermark B. Well-being and its relation to coping ability in patients with colo-rectal and gastric cancer before and after surgery. Scand J Caring Sci. 1996;10(1):35-44. doi: 10.1111/j.1471- 6712.1996.tb00308.x. No exposure of interest. 13. Frost MH, Johnson ME, Atherton PJ, Petersen WO, Dose AM, Kasner MJ, Burger KN, Sloan JA, Pipe TB. Spiritual well-being and quality of life of women with ovarian cancer and their spouses. J Support Oncol. 2012 Mar-Apr;10(2):72-80. doi: 10.1016/j.suponc.2011.09.001. No association of interest. 14. Gravier AL, Shamieh O, Paiva CE, Perez-Cruz PE, Muckaden MA, Park M, Bruera E, Hui D. Meaning in life in patients with advanced cancer: a multinational study. Support Care Cancer. 2020 Aug;28(8):3927-3934. doi: 10.1007/s00520-019-05239-5. No outcome of interest. Fatigue appears as an exposure and meaning in life as an outcome. 15. Groarke A, Curtis R, Walsh DMJ, Sullivan FJ. What predicts emotional response in men awaiting prostate biopsy? BMC Urol. 2018 Apr 24;18(1):27. doi: 10.1186/s12894-018-0340-9. No exposure of interest. 16. Grumann MM, Spiegel D. Living in the face of death: interviews with 12 terminally ill women on home hospice care. Palliat Support Care. 2003 Mar;1(1):23-32. doi: 10.1017/s1478951503030116. No association of interest. 17. Harandy, T.F., Ghofranipour, F., Montazeri, A. et al. Health-Related Quality of Life in Iranian Breast Cancer Survivors: A Qualitative Study. Applied Research Quality Life 5, 121–132 (2010). https://doi.org/10.1007/s11482-010-9097-3 No association of interest. 18. Helgeson VS, Tomich PL. Surviving cancer: a comparison of 5-year disease-free breast cancer survivors with healthy women. Psychooncology. 2005 Apr;14(4):307-17. doi: 10.1002/pon.848. No association of interest. Excluded reviews Reason 19. Hicks J, Bartholomew J, Ward-Smith P, Hutto CJ. Quality of life among childhood leukemia patients. J Pediatr Oncol Nurs. 2003 Jul-Aug;20(4):192-200. doi: 10.1177/1043454203253969. No association of interest. 20. Hiensch AE, Bolam KA, Mijwel S, May AM, Wengström Y. Sense of coherence and its relationship to participation, cancer-related fatigue, symptom burden, and quality of life in women with breast cancer participating in the OptiTrain exercise trial. Support Care Cancer. 2020 Nov;28(11):5371-5379. doi: 10.1007/s00520-020-05378-0. No exposure of interest. 21. Hiratsuka Y, Suh SY, Kim SH, Cheng SY, Yoon SJ, Koh SJ, Park SA, Seo JY, Kwon JH, Park J, Park Y, Hwang SW, Lee ES, Ahn HY, Hui D, Chen PJ, Yamaguchi T, Morita T, Tsuneto S, Mori M, Inoue A; the EASED Investigators. Factors related to spiritual wellbeing in the last days of life in three East Asian countries: An international multicenter prospective cohort study. Palliat Med. 2021 Sep;35(8):1564-1577. doi: 10.1177/02692163211022179. No outcome of interest. Fatigue appears as an exposure and spiritual well-being as an outcome. 22. Kim Y, Yen IH, Rabow MW. Comparing Symptom Burden in Patients with Metastatic and Nonmetastatic Cancer. J Palliat Med. 2016 Jan;19(1):64-8. doi: 10.1089/jpm.2011.0456. No association of interest. 23. Magyari F, Kósa K, Berecz R, Illés A, Miltényi Z, Simon Z, Illés Á. Employment status and health related quality of life among Hodgkin-lymphoma survivors'- results based on data from a major treatment center in Hungary. Health Qual Life Outcomes. 2017 Sep 19;15(1):180. doi: 10.1186/s12955-017-0758-x. No exposure of interest. 24. Majda A, Szul N, Kołodziej K, Wojcieszek A, Pucko Z, Bakun K. Influence of Spirituality and Religiosity of Cancer Patients on Their Quality of Life. Int J Environ Res Public Health. 2022 Apr 19;19(9):4952. doi: 10.3390/ijerph19094952. No exposure of interest. The authors measured the level of spirituality/religiosity. 25. Manalo MF, Ng S, Ozdemir S, Malhotra C, Finkelstein EA, Ong KD, Teo I. Quality of life and psychological No association of interest. Excluded reviews Reason distress of patients with advanced cancer in the Philippines. Qual Life Res. 2023 Aug;32(8):2271-2279. doi: 10.1007/s11136-023-03389-y. 26. Mendes BV, Donato SCT, Silva TLD, Penha RM, Jaman-Mewes P, Salvetti MG. Spiritual well-being, symptoms and performance of patients under palliative care. Rev Bras Enferm. 2023 Apr 7;76(2):e20220007. doi: 10.1590/0034-7167-2022-0007. Cancer was jointly analyzed with other health conditions. 27. Miller M, Kwekkeboom K, Cherwin C. The role of spirituality in symptom experiences among adults with cancer. Support Care Cancer. 2022 Jan;30(1):49-57. doi: 10.1007/s00520-021-06399-z. No exposure of interest. The authors measured spirituality, but this factor was not spiritual well-being. 28. Moreno PI, Dooley LN, Bower JE. Unique associations of eudaimonic and hedonic wellbeing with psychosocial adjustment in breast cancer survivors. J Psychosoc Oncol. 2018 Sep-Oct;36(5):649-657. doi: 10.1080/07347332.2018.1471564. No exposure of interest. The authors measured eudaimonic and hedonic well-being. 29. Persson L, Hallberg IR. Acute leukaemia and malignant lymphoma patients' experiences of disease, treatment and nursing care during the active treatment phase: an explorative study. Eur J Cancer Care (Engl). 1995 Sep;4(3):133-42. doi: 10.1111/j.1365- 2354.1995.tb00071.x. No exposure of interest. 30. Persson L, Hallberg IR, Ohlsson O. Survivors of acute leukaemia and highly malignant lymphoma-- retrospective views of daily life problems during treatment and when in remission. J Adv Nurs. 1997 Jan;25(1):68-78. doi: 10.1046/j.1365- 2648.1997.1997025068.x. No exposure of interest. 31. Pierzynski JA, Clegg JL, Sim JA, Forrest CB, Robison LL, Hudson MM, Baker JN, Huang IC. Patient-reported outcomes in paediatric cancer survivorship: a qualitative study to elicit the content from cancer survivors and caregivers. BMJ Open. 2020 May 17;10(5):e032414. doi: 10.1136/bmjopen-2019-032414. No association of interest. 32. Randazzo DM, McSherry F, Herndon JE 2nd, Affronti ML, Lipp ES, Miller ES, Woodring S, Healy P, Jackman No association of interest. Chou et al. 2022; Taiwan N = 416 Age mean= 62.4 (SD 11.4) F (n= 160) Presence of comorbidities (n=220, 52.9%) Colorectal cancer (N= 416) of which colon cancer (N= 285) Stage 0: 1.9% Stage I: 28.6% Stage II: 33.4% Stage III: 36.1% < 0.5 years (n= 107, 25.7%), 0.5 to 1 year (n= 100, 24%), 1 to 2 years (n= 103, 24.8%), 2 to 5 years (n= 106, 25.5%) No Outpatients who completed treatment (N= 272) Religious affiliation or level of religiosity: UR Educational stage: mean (SD): 12.3 (4.5) years. Incomes: UR Ethnic/race: UR Purpose (subdomain of RS) Spiritual well-being (FACIT-Sp) Fatigue (FSI) Correlations: Purpose: r = -0.206 p < 0.001 Spiritual well-being: r = -0.331 p < 0.001 Coleman et al. 2022; USA N = 91 Age mean= 46.4 F (n= 91) Two or more comorbidities (≈30%) Cervical cancer (N= 91) Stage I: 54.9% Stage II: 6.6% Stage III: 26.4% Stage IV: 6.6% Not applicable: 4.4% Stage unknown: 1.1% UR Yes Pain (PROMIS) No. Patients underwent chemotherapy (60.4%) and radiation therapy (63.7%) Religious affiliation or level of religiosity: UR Educational stage: < high school graduate (n= 32, 35.6%), high school graduate (n= 17, 18.7%), some college (n= 28, 31.1%), college degree (n= 8, 8.8%), graduate degree (n= 4, 4.4%), unsure (n= 1, 1.1%) Incomes: Less than $10,000 (n= 22, 24.2%), $10,000 to Spiritual well-being (FACIT-Sp) Fatigue (PROMIS from the SPADE symptom cluster) Correlation: UR Linear regression: Spiritual well-being: β= −0.41 p <0.01 Transformed data: r= - 0.41 $59,999 (n= 40, 46%), $60,000 to $99,999 (n= 7, 7.7%), $100,000 to $199,999 (n= 3, 3.3%), $200,000 or more (n= 3, 3.3%), unsure (n= 10, 11%), refuse to answer (n= 2, 2.2%) Ethnic/race: Non-Hispanic black (n= 22, 24.2%), Latinas (n= 51, 56%), Non-Hispanic Asian (n= 18, 19.8%) Grossoehme et al. 2020; USA N = 126 Age mean= 16.9 (SD 1.9) F (n= 72) UR Leukemia (N= 42), Lymphoma (N= 19), Solid tumors (N= 34), Brain tumor (N= 25), Other (N= 36) Cancer stages: UR UR Yes Pain interference (PROMIS): 43.8 (10.3) On active treatment (n= 27, 21.4%), Not on active treatment (n= 99, 78.6%), Religious affiliation or level of religiosity: Agnostic/atheist/none (n= 24, 19%), Christian (n= 90, 71.4%), Hindu (n= 1, 0.8%), Jehovah’s Witness (n= 1, 0.8%), Jewish (n= 1, 0.8%), LDS/Mormon (n= 6, 4.8%), Missing (n= 3, 2.4%), Educational stage: UR Incomes: UR Faith (subdomain of FACIT- Sp) Spiritual well-being (FACIT-Sp) Fatigue (PROMIS) Structural equation model: Faith: β = 2.12 (95% CI, -0.85 to 5.46) p= UR Spiritual well-being: UR Ethnic/race: Race: Asian (n= 3, 2.4%), Black or African American (n= 17, 13.5%), White (n= 100, 79.4%), American Indian or Alaska Native (n= 0, 0%), > 1 race (n= 5, 4%), declined to answer (n= 1, 0.8%) Ethnicity: Hispanic or Latino (n= 5, 4%), Not Hispanic or Latino (n= 116, 92.1%), declined to answer (n= 5, 4%) Jin et al. 2022a; South Korea N = 169 Age mean= 48.9 (SD 7.27) F (n= 169) UR Breast cancer (N= 169) Stage I: 46.2% Stage II: 39.1% Stage III: 14.8% 1 year (n= 8, 4.7%), 2 years (n= 47, 27.8%), 3 years (n= 26, 15.4%), 4 years (n= 30, 17.8%), 5 years (n= 58, 34.3%), No No current cancer treatment (n= 56, 33.1%), ≤ 2 cancer treatments in progress, e.g., radiation therapy, targeted therapy hormone therapy (n= 113, 66.9%) Religious affiliation or level of religiosity: None (n= 39, 23.1%), Catholic (n= 61, 36.1%), Protestant (n= 35, 20.7%), Buddhism (n= 34, 20.1%) Educational stage: high school (n= 42, 24.9%), college (n= 95, 56.2%), graduate school (n= 32, 18.9%) Spiritual well-being (SWBS) Fatigue (FACIT-Fatigue) Correlations: Spiritual well-being: r = -0.06 (n/s) Incomes (monthly net income, won): < 150 (n= 34, 20.1%), 150 - 249 (n= 66, 39.1%), 250 - 349 (n= 31, 18.3%), ≥ 350 (n= 38, 22.5%) Ethnic/race: UR Jin et al. 2022b; South Korea N = 182 Age: ≤ 30s (n= 16), 40s (n= 69), 50s (n= 79), 60s (n= 18). F (n= 182) UR Thyroid cancer, (N= 37), Gynecological cancer (N= 15), Breast cancer (N= 106), Gastric cancer (N= 14), Others (N= 10) Stage I: 47.8% Stage II: 36.8% Stage III: 15.4% UR No No current cancer treatment (n= 74, 40.7%), 1 to 2 current cancer treatments (n= 108, 59.3%) Religious affiliation or level of religiosity: Catholic (n= 61, 33.5%), Protestant (n= 40, 22%), Buddhism (n= 41, 22.5%), Others (n= 40, 22%) Educational stage: high school (n= 55, 30.2%), college (n= 95, 52.2%), graduate school (n= 32, 17.6%) Incomes (monthly income, 10,000 won): < 150 (n= 42, 23.1%), 150 <∼≤ 250 (n= 68, 37.4%), 250 <∼≤ 350 (n= 34, 18.7%), > 350 (n= 38, 20.9%) Spiritual well-being (SWBS) The authors used the two dimensions of this exposure: existential and religious wellbeing Fatigue (FACIT-Fatigue) Correlations: Spiritual well-being: UR Existential well-being: r = - 0.206 p < 0.001 Religious well-being: r = - 0.023 (n/s) Ethnic/race: UR Kandasamy et al. 2011; India N = 50 Age mean= 49.7 (SD 10.17) F (n= 28) UR Oropharyngeal cancer, (N= 11), Gynecological cancer (N= 11), Lung cancer (N= 6), Breast cancer (N= 6), Stomach cancer (N= 5), Others (N= 11) Cancer stages: UR UR Yes Pain interference (VAS) Advanced cancer (no further curative treatments available) Religious affiliation or level of religiosity: UR Educational stage: UR Incomes: UR Ethnic/race: UR Spiritual well-being (FACIT-Sp) Fatigue (MDASI) Correlations: Spiritual well-being: r = - 0.423 p = 0.002 Lee 2021; South Korea N = 132 Age mean= 66 (SD 9.1) F (n= 37) Presence of comorbidities (n=43, 32.6%) No presence of comorbidities (n=89, 67.4%) Non-small cell lung cancer (N= 132) Stage I: 7.3% Stage II: 5.6% Stage III: 27.4% Stage IV: 59.7% < 1 year (n=87, 65.9%), ≥ 1 to < 2 years (n=21, 15.9%), ≥ 2 years (n=24, 18.2%) Yes Pain interference (subdomain of EORTCQLQ-C30): 30.7 (SD 39.4) Chemotherapy treatment (n= 101, 76.5%), radiotherapy treatment (n= 19, 14.4%), concurrent chemoradiotherapy (n= 12, 9.1%) Religious affiliation or level of religiosity: Practice a religion (n= 76, 57.6%), non-practice a religion (n= 56, 42.4%) Educational stage: UR Incomes (monthly income, US $): < 2,000 (n= 107, 81.1%), ≥ 2,000 (n= 25, 18.9%) Ethnic/race: UR Spiritual well-being (FACIT-Sp) Fatigue (subdomain of EORTC-QLQ- C30) Correlations: Spiritual well-being: r = - 0.29 p < 0.001 Leeson et al. 2015; USA N = 220 Age mean= 51 (19-74) F (n= 84) UR Leukemias (N= 74), Lymphomas (N= 69), Multiple myeloma (N= 69), Other (N= 8) UR Yes Pain (BPI): 30.7 (SD 39.4) Hematopoietic stem cell transplantation (n= 220) Religious affiliation or level of religiosity: Lutheran (n= 56, 25.5%), Catholic (n= 51, 23.2%), Methodist (n= 21, 9.5%), Faith (subdomain of FACIT- Sp) Spiritual well-being Fatigue (FSI) Mixed-effects linear regression Models: Faith (main effect): Cancer stages: UR All these participants had previously had chemotherapy. Other (n= 54, 24.6%), None (n= 32, 14.5%), declined to respond (n= 6, 2.7%) Educational stage: Less than 12 years (n= 7, 3.2%), high school (n= 59, 26.8%), some college/trade (n= 59, 26.8%), college graduate (n= 59, 26.8%), postgraduate degree (n= 36, 16.4%) Incomes (annual household income, US$): < 25,000 (n= 30, 13.7%), 25,000 – 55,000 (n= 62, 28.2%), 55,000 – 85,000 (n= 58, 26.4%), 85,000 (n= 57, 25.9%), declined to respond (n= 13, 5.9%) Ethnic/race: White (n= 213, 96.8%), Native American (n= 2, 0.9%), African American (n= 2, 0.9%), Latina/o (FACIT-Sp) Coef. = 0.085, z = 1.97 p = 0.049 Transformed data: z= 0.961 Spiritual well-being: UR (n= 1, 0.5%), declined to respond (n= 1, 0.5%) Lewis et al. 2014; India N = 200 Age mean= 50.4 (SD 13.1) F (n= 123) UR Head and neck cancer (N= 53), Breast cancer (N= 38), Gynecological cancer (N= 37), Gastrointestinal cancer (N= 53), Others (sarcoma, lymphoma, thyroid, hepatocellular carcinoma…, N= 19) Stage I: 4.5% Stage II: 24.5% Stage III: 59.5% Stage IV: 11.5% UR No Cancer therapy (n= 66, 33%), radiation therapy (n= 44, 22%), cancer therapy + radiation therapy (n= 86, 43%), other (n= 4, 2%) Religious affiliation or level of religiosity: UR Educational stage: UR Incomes: UR Ethnic/race: UR Spiritual well-being (FACIT-Sp) Fatigue (FACIT-Fatigue) Correlation: Spiritual well-being: r = - 0.277 p < 0.01 Linear regression analysis (standard coefficient) Spiritual well-being: β = −0.230 (95% CI, - 0.351 to -0.094) p = 0.001 Rabow et al. 2015; USA N = 883 Age mean= 65.6 F (n= 478) UR Breast cancer (N= 263), Genitourinary cancer (N= 225), Gastrointestinal cancer (N= 151), Gynecologic cancer (N= 105), Head and neck cancer (N= 51), Lung cancer (N= 51), Brain cancer (N= 18), Sarcoma (N= 17) Cancer stages: Metastatic: 51.2% Localized: 48.7% UR Yes Pain (ESAS) UR Religious affiliation or level of religiosity: Christian (n= 179, 20.3%), Catholic (n= 165, 18.7%), Jewish (n= 77, 8.7%), Buddhist (n= 19, 2.2%), Mormon (n= 6, 0.7%), Hindu (n= 3, 0.3%), Muslim (n= 1, 0.1%), Other (n= 29, 3.3%), No response (n= 78, 8.8%), None (n= 325, 36.8%) Peace (the validated Steinhauser screening question, “I feel at peace”) Fatigue (ESAS) Correlation: Peace: r data UR p = 0.005 (greater spiritual wellbeing associated with less fatigue) Multiple regression analysis: Data UR Educational stage: UR Incomes: UR Ethnic/race: White (n= 612, 69.3%), Asian (n= 88, 10%), African American (n= 55, 6.2%), Other (n= 125, 14.2%) Yang et al. 2023; China N = 108 Age mean= 65.2 (SD 12.5) F (n= 56) UR Cancer sites: UR Cancer stages: UR UR Yes Pain (NRS): 6.41 (SD 3.18) UR Religious affiliation or level of religiosity: UR Educational stage: Middle school (n= 54, 50.5%), high school (n= 28, 26.2%), Junior college or above (n= 25, 23.3%) Incomes: UR Ethnic/race: UR Spiritual well-being (FACIT-Sp) Faith (subdomain FACIT- Sp) Peace (subdomain FACIT- Sp) Fatigue (CFS) Correlations: Spiritual well-being: r = -0.542 p < 0.001 Faith: r = -0.486 p < 0.001 Peace: r = -0.416 p < 0.001 Note: (n/s): results were not statistically significant; SD: standard deviation; CI: confidence interval; b: beta coefficient; β: standardized beta coefficient; r: correlation coefficient; OR: odds ratio; F: female; M: male; UR: unreported. BPI: Brief Pain Inventory; CFS: Cancer Fatigue Scale; CIS: Checklist Individual Strength; IBCSG-QL: International Breast Cancer Study Group Quality of Life; EORTC-QLQ-C30: European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30; ESAS: Edmonton Symptom Assessment Scale; FACIT-Sp: Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale; FACT-G: Functional Assessment of Cancer Therapy – General; FSI: Fatigue Symptom Inventory; FSQoLS: Fox Simple Quality of Life Scale: HDI: Health and Disease Inventory; IPOS: Integrated Palliative Outcome Scale; LAP-R: Life Attitude Profile-Revised; MDASI: M.D. Anderson symptom inventory; MIL: Meaning in Life; MILS: Meaning in Life Scale; MSAS: Memorial Symptom Assessment Scale; NRS, Numeric Rating Scale; PFS, Piper Fatigue Scale; PIL, Purpose in Life; PROMIS: Patient-Reported Outcomes Measurement Information System (PROMIS); RS: Resilience Scale; SCSORF: Santa Clara Strength of Religious Faith Questionnaire; SF-12: 12-item Short Form Health Survey; SPADE: Sleep disturbance, pain, anxiety, depression, and low energy/fatigue; SWBS: Spiritual Well-Being Scale; VAS, Visual Analogue Scale; WHOQOL-SRPB: World Health Organization Quality of life – Spirituality, Religiousness, and Personal Beliefs. Supplementary File 4. The methodological quality of cross-sectional studies. Author(s) 1 2 3 4 5 6 7 8 Aukst-Margetic et al. 2009 Unclear No No Yes No No Unclear Yes Brandão et al. 2021 No Yes Yes Yes No No Yes Yes Chou et al. 2022 Yes Yes Yes Yes Yes Yes Yes Yes Coleman et al. 2022 Unclear Yes Yes Yes Yes Yes Yes Yes Grossoehme et al. 2020 Yes Yes Yes Yes Yes Yes Yes Yes Jin et al. 2022a Yes Yes Yes Yes No No Yes Yes Jin et al. 2022b Yes Yes Yes Yes No No Yes Yes Kandasamy et al. 2011 Yes No Yes Yes No No Yes Yes Lee 2021 Yes Yes Yes Yes No No Yes Yes Leeson et al. 2015 Unclear No Yes Yes Yes Yes Yes Yes Lewis et al. 2014 Yes No Yes Yes Yes No Yes Yes Rabow et al. 2015 Unclear Yes Unclear Yes No No Yes Yes Yang et al. 2023 No No Yes Yes Yes Yes Yes Yes Response options: Yes / No / Unclear / Not applicable Item 1: Were the criteria for inclusion in the sample clearly defined? Item 2: Were the study subjects and the setting described in detail? Item 3: Was the exposure measured in a valid and reliable way? Item 4: Were objective, standard criteria used for measurement of the condition? Item 5: Were confounding factors identified? Item 6: Were strategies to deal with confounding factors stated? Item 7: Were the outcomes measured in a valid and reliable way? Item 8: Was appropriate statistical analysis used?