Here’s something I wrote, for a class while I was a student at the Canadian College ion naturopathic Medicine (I don’t remember which class, but something women’s health- or oncology-related seems like a reasonable guess).

Prayer came up recently, somehow, in an appointment of Du’s, and she asked me if I still had any references from “that paper I wrote”, so I found them.

Anyway, I re-read it, and it was kind of interesting, so …

– Jonah Lusis, ND

Spirituality in the Experience of Breast Cancer

Submitted: 2002 March 21

The purpose of this paper is to briefly review the use and relevance spirituality in the experience and treatment of breast cancer. As a topic of discussion in medicine, faith in healing is often the subject of controversy. However, as Margaret Meade is quoted on prayer (which will also be discussed below) by Dossey, spirituality similarly “does not use any artificial energy, it doesn’t burn up any fossil fuel, it doesn’t pollute.” And as Dossey added “it apparently works.”¹ Before we begin our examination of spirituality in healing, let us define our key term. As the concept of spirituality understood differently by every person, we have chosen to describe it in broad terms as a relationship with “the Absolute”.

Prayer Amongst Women With Breast Cancer

Published studies repeatedly indicate prayer as one of the primary forms of complementary medicine employed by women with breast cancer.^{2, 3, 4} A study by VandeCreek et al. found that prayer is used as a complementary therapy by breast cancer outpatients more often than in outpatients in general (76% versus 25% of the time).⁵ This study also found that prayer was the most commonly used alternative therapy by women with breast cancer, and that 84% of the breast cancer outpatients prayed.⁵ More specifically, it is the most common form of complementary medicine used by black women with breast cancer (36%), and the second most common used by Latino women (26%) with breast cancer.² Although the studies cited conclude that demographically, women who use prayer as a form of treatment for breast cancer are in general more educated^{2, 3, 4}, wealthier², and younger² than those who rely on conventional medicine alone, we feel these results may in fact be a result of these studies having measured the prevalence of use of a number of alternative therapies including prayer amongst them, as opposed to the prevalence of the use of prayer specifically. The cost effectiveness of prayer suggests it would be widely used by those in lower socioeconomic classes.

Participation in Religion has Benefits Unrelated to Spiritual Healing

One of the difficulties in investigating the effects of spirituality on health is separating the effects of faith and the effects of lifestyles associated with participation in religion. Examples of this effect can be found in the findings of very low rates of oral and lung cancers among Amish and Hutterite populations whose smoking prevalence approaches zero. Although predictions of this type are not infallible (in the same study it was found that Amish and Hutterite women have unusually high rates of breast cancer which does not seem to be related to any aspect of their lifestyle), the author was none the less able to conclude that “Religions that provide strong directives for the personal lives of adherents result in distinctive life-style, reflecting multiple disease related factors.”⁶ These findings are repeated in an exhaustive review of literature by Levin.⁷ Simply put, a lifestyle free of vice is good for ones health.

A second salient aspect of religious affiliation and health is the presence of support on a bodily level. People involved in religious communities are often cared for by other members of their community when they fall on difficult times. Those without this support are at a disadvantage in carrying out simple tasks of daily living such as buying groceries, maintaining their homes, etc. This is a particularly important consideration in the case of the elderly. Although compelling, and related to issues of faith, these topics fall outside the scope of the present discussion.

Benefits of Spirituality in Health Commonly Accepted in Science and Medicine

One area in which the benefit of prayer and spirituality on health is now for the most part accepted is in its psychological role of providing a sense of purpose and comfort to those who are sick. Using a group of Harvard undergraduate students as subjects, by measuring their stress and depression levels using a standardized psychological scale and by interview and comparing it to their “natural killer” (NK) cell activity, Locke demonstrated that those with higher levels of stress or who were more depressed had depressed NK cell activity.⁸ Kiecolt-Glaser and Glaser showed alternatively, that elderly subjects who were given relaxation training three times weekly (and who self-reported lower levels of stress as a result) showed significantly increased NK cell and T cell activity.⁹

Similarly, studies have been published illustrating the link between a sense of helplessness (i.e. the sense that one has no control over their stressor) and depressed immune function. Weiss illustrated this in rat studies. In the experiment, one group of rats was able to control whether or not they received electrical shocks by rotating a wheel. The health outcomes of these rats were compared to those of a second group of rats that had no control over whether they would be shocked (i.e. were more helpless). They found that the “helpless” rats experienced poorer health outcomes in the form of development of ulcers.¹⁰

Feelings of despair and loneliness have also been found to lower immune function. A classic study by Parkes on widowers illustrated this in 1969. In this study Parkes monitored the health of 4448 widowers and found that their death rate was unusually high in the six months following the death of their spouses.¹¹ A more distinct relationship between bereavement and immune function was illustrated in a study by Schleifer in which the T- and B-lymphocytes of men whose wives were suffering from terminal breast cancer was evaluated. It was found that although their wives death did not affect the numbers of their circulating lymphocytes, it affected lymphocyte function. Lymphocytes that had showed normal function prior to spousal death showed no function after their spouses succumbed to the disease, even when stimulated chemically in vitro.¹²

Lastly, in a five year study of HIV patients, Theorell et al. found that those who scored low on “availability of attachment” scales (i.e., were lonely) had a much more rapid decline in CD4+ cell count than those who had more social support.¹³ Feelings of stress, helplessness, despair, and of “being alone” are all associated with a cancer diagnosis, and can be addressed using spiritual counseling.

Regarding faith and illness outcomes in practice, it has been shown that having faith from which to draw strength is of benefit to post-operative cardiac patients. Those without religious affiliation were three times as likely to die in the six months following surgery when compared to those who were religiously active.¹⁴

 In breast cancer specifically, there are a number of psychological factors associated with religion and illness outcomes. Expression of hostility towards the cancer, described in one study as “fighting spirit”¹⁵ (as opposed to stoic acceptance) is associated with longer survival.¹⁶ This type of psychological hardiness is fostered by a relationship with God (in the case of a Christian).⁵

Two aspects of the complexity of this relationship and its relationship to benefit in disease have been examined by Gall et al. and Mickley in separate studies. Gall and his colleagues found that those who regarded their personal deity as a vengeful or angry god experienced greater psychological distress in disease than those who felt their god was a benevolent being.¹⁷ We may infer that those praying to what they believe to be a benevolent god will have better cancer outcomes as well. Mickley examined the question: do those who turn to a greater power only in time of need have the same outcomes as those who have an ongoing relationship with their god? Mickley measured the spiritual well-being of women who had been diagnosed with breast cancer as a function of whether they were intrinsically or extrinsically religious (as determined by questionnaire). It was found that women who were classified as intrinsically religious had significantly higher scores in spiritual well-being than women who were extrinsically religious.¹⁸ We may conclude that having a “genuine” relationship with one’s god is more beneficial to cancer outcomes than praying only when one needs help. A simple explanation (from the psychoneuroimmunological standpoint) for this may be that those who turn to their god only in time of need likely do not have any realistic expectation of a response, although there are likely many other factors involved (both psychologically and theologically).

Benefits of Spirituality in Health Not-So-Commonly Accepted in Science and Medicine

Likely the most controversial aspect of the faith-health discussion revolves around the efficacy of intercessory prayer (i.e., when one party prays on behalf of another) as a treatment intervention. Perhaps the most well recognized study examining intercessory prayer was conducted by Byrd in 1982-83. In his study involving coronary care patients, Byrd selected as intercessors “active” Christians. “Active” was manifested by daily devotional prayer and active fellowship with a local church. Each patient in the study group was paired with between three and seven intercessors. The intercessors knew only the patients first name, diagnosis, general condition, and were updated as to the patient’s condition as necessary. Intercessory prayer was done outside the hospital daily until the patient was discharged. The intercessors were asked to pray for rapid recovery, prevention of complications and death, and anything else they deemed pertinent. In the final analysis, the prayer group had more “good” outcomes (85% versus 73%) and less “bad” outcomes (14% versus 22%) compared to controls.¹⁹ A possible confound in this study is that although the subjects did not know whether they were in the experimental or control group, they were aware that they were involved in a prayer study, and may therefore had some expectation of a positive outcome. This factor is further confounded by the fact that 57 subjects originally selected for the Byrd study refused to be included for personal or reasons of religious conviction. Byrd’s study cohort was therefore composed entirely of “prayer receptive” subjects.

Harris et al. attempted to correct for these confounds in Byrd’s study by conducting a similar study, also involving coronary care patients, in which the patients involved were not aware that they were being prayed for. As no known risk is associated with intercessory prayer, consent was deemed unnecessary. The hospital staff was completely blinded and the criteria and instructions for intercessors were the same as in the Byrd study. The outcomes in this study were similar to Byrd’s: patients in the prayer group had favorable overall scores for adverse outcomes, but had similar duration of length of hospital stay.²⁰

An interesting study was conducted by Leibovici in 2001 in which he examined retroactive intercessory prayer. The a priori assumption in this study was that God is not limited to linear time the way we are, and therefore retroactive intercessory prayer can be considered a reasonable experimental medical intervention. In this study, 3393 patients diagnosed with bloodstream infection in a hospital population were randomized into two groups. One group was prayed for and the other was not. Leibovici’s results showed that those in the experimental group had less mortality (28.1% versus 30.2%) and had significantly shorter durations of hospital stay compared to controls.²¹ It should be noted that in spite of having endorsed the use of intercessory prayer as a medical intervention based on the study outcome, Leibovici is a well known skeptic of alternative medicine and it is suspected that this study was undertaken primarily as a means of mocking the study of prayer in medicine and igniting controversy (which it did).

Finally, a review article of 23 randomized trials of distant healing, including intercessory prayer, found that 57% of the studies reviewed showed positive effect. Of those 23 studies, five (including the aforementioned studies by Byrd and Harris et al.) were of intercessory prayer. Three of the five studies showed significant favorable effects for intercessory prayer, one showed marginal favorable effects, and one showed no effect. All five studies involved prayer in the Christian tradition.²² Although we were able to find no published studies specifically examining the relationship between intercessory prayer and breast cancer, presumably the results are transferable.

As compelling as these positive study results are, there are at least three important caveats to bear in mind regarding intercessory prayer:

1. There is no known mechanism. In response to this, proponents of prayer as a viable medical intervention will point out that no mechanism is necessary to illustrate effect, and often demonstration of empirical facts precedes the development of a scientifically acceptable explanation. An example is Semmelweis’ observation in 1848 that washing one’s hands before surgery reduced patient mortality. Before the development of germ theory this was not a part of medical thought and Semmelweis was ostracized for suggesting it.
2. It is impossible to design a study with a “pure” control group. There can never be any guarantee (in fact it is quite unlikely) that those in the control group are not being prayed for by someone other than an official intercessor. Presumably “the Absolute” does not ignore the prayers of those outside an experimental group. Although we do not suppose that divine intervention can be reduced to simple mathematics, it may be argued that as the outcomes for control groups in these studies was not zero, perhaps the intercessors interventions account for the differences between the two groups results.
3. Ultimately, prayers often go unanswered. As Nancy Willard is quoted as saying: “If prayers worked, Hitler would have been stopped at the border of Poland by angels with swords of fire.”²³

Relevance to the Clinician

In closing we can safely conclude that the clinician can expect that for many of their patients, breast cancer and otherwise, prayer and faith will be an important part of their experience of both their illness and recovery, and maybe death. Spirituality will at the very least be a source of comfort to them, and possibly more. Patients want physicians to be willing to discuss their coping mechanisms and respect their values²⁴, and it is important that we remember this.

References

1. Meade M. Quoted in: Dossey L. The return of prayer. Alternative Therapies in Health and Medicine. 1997;3(6):10-17, 113-20.
2. Lee MM, Lin SS, Wrensch MR, Adler SR, Eisenberg D. Alternative therapies used by women with breast cancer in four ethnic populations. Journal of the National Cancer Institute. 2000;92(1):42-7.
3. Tataryn D. Beyond convention: Describing complementary therapy use by women living with breast cancer. Patient Education and Counseling. 1999;36(1):143-53.
4. Wyatt GK, Friedman LL, Given BA, Beckrow KC. Complementary therapy use among older cancer patients. Cancer Practice. 1999;7(3):136-44.
5. VandeCreek L, Rogers E, Lester J. Use of alternative therapies among breast cancer outpatients compared with the general population. Alternative Therapies in Health and Medicine. 1999;5(1):71-6.
6. Troyer H. Review of cancer among 4 religious sects: evidence that life-styles are distinct sets of risk factors. Social Science Medicine. 1988;26(10):1007-17.
7. Levin JS. Religion and health: is there an association, is it valid, and is it causal? Social Science Medicine. 1994;38(11):1475-82.
8. Locke S, Colligan D. The healer within: the new medicine of mind and body. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 90.
9. Reference not available. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 90.
10. Reference not available. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 91.
11. Reference not available. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 91.
12. Reference not available. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 92.
13. Theorell T, Blomkvist V, Jonsson H, Schulman S, Berntorp E, Stigendal L. Social support and development of immune function in human immunodeficiency virus infection. In: Watkins A, ed. Mind-body medicine: a clinicians guide to psychoneuroimmunology. New York, NY: Churchill-Livingston; 1997: 121.
14. Oxman T, Freeman D, Manheimer E. Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly. In: VandeCreek L, Rogers E, Lester J. Use of alternative therapies among breast cancer outpatients compared with the general population. Alternative Therapies in Health and Medicine. 1997;5(1):71-6.
15. Cotton SP, Levine EG, Fitzpatrick CM, Dold KH, Targ E. Exploring the relationships among spiritual well-being, quality of life, and psychological adjustment in women with breast cancer. Psychooncology. 1999;8(5):429-38.
16. Magary CJ. Aspects of the psychological management of breast cancer. Medical Journal of Australia. 1988;148(5):239-42.
17. Gall TL, de Renart RMM, Boonstra B. Religious resources in long-term adjustment to breast cancer. Journal of Psychosocial Oncology. 2000;18(2):21-37.
18. Mickley JR, Soeken K, Belcher A. Spiritual well-being and hope among women with breast cancer. Journal of Nursing Scholarship. 1992;24(4):267-72.
19. Byrd RC. Positive therapeutic effects of intercessory prayer in a coronary care population. Southern Medical Journal. 1988;81(7):826-29.
20. Harris WS, Manohar G, Kolb JW, Strychacz CP, Vacek JL, Jones PG, et al. A randomized, controlled trial of the effects of remote, intercessory prayer on outcomes in patients admitted to the coronary care unit. Archives of Internal Medicine. 1999;159:2273-78.
21. Leibovici L. Effects of remote, retroactive intercessory prayer on outcomes in patients with bloodstream infection: randomized controlled trial. British Medical Journal. 2001;323:1450-51.
22. Astin JA, Harkness E, Ernst E. The efficacy of “distant healing”: a systematic review of randomized trials. Annals of Internal Medicine. 2000;132:903-10.
23. Willard N. Quoted in: Dossey L. The return of prayer. Alternative Therapies in Health and Medicine. 1997;3(6):10-17, 113-20.
24. Hebert RS, Jenckes MW, Ford DE, O’Conner DR, Cooper LA. Patient perspectives on spirituality and the patient-physician relationship. Journal of General Internal Medicine. 2001;16(10):685-92.