BACKGROUND:Psychosocial factors are argued to increase cancer risk. This study aims to clarify the association between various psychosocial factors and cancer incidence (including breast, lung, prostate, and colorectal cancers) via individual-participant data (IPD) meta-analysis. The psychosocial factors considered were perceived social support (PSS), loss, relationship status, neuroticism, and general distress. METHODS:The Psychosocial Factors and Cancer Incidence consortium used data from 22 cohorts with a measure of at least one psychosocial variable of interest at baseline (up to N = 421,799; cancer incidence, N = 35,319; person-years of follow-up, N = 4,378,582). In stage 1 of the IPD meta-analysis, Cox regression models were used with age as the timescale. In stage 2, results were pooled in random-effects meta-analyses. RESULTS:No psychosocial factors were associated with an increased risk of overall cancer and with breast, prostate, and colorectal cancers, as well as with cancers with alcohol as a common potential causal factor. PSS, currently not in a relationship, and a loss event were associated with an increased risk of lung cancer (hazard ratio [HR], 1.09-1.55). Estimates decreased for PSS and relationship status when adjusting for several known risk factors, such as a family history of cancer (HR, 1.05-1.08). Similar findings were observed for relationship status and cancers with tobacco smoking as a common potential causal factor. CONCLUSIONS:For most types of cancer, psychosocial factors (measured at a single point in time) were not associated with increased risk. PSS, currently not in a relationship, and loss were associated with an increased risk of lung cancer, although most effects attenuated when adjusting for several known risk factors.

Background Although behavioral mechanisms in the association among depression, anxiety, and cancer are plausible, few studies have empirically studied mediation by health behaviors. We aimed to examine the mediating role of several health behaviors in the associations among depression, anxiety, and the incidence of various cancer types (overall, breast, prostate, lung, colorectal, smoking-related, and alcohol-related cancers).Methods Two-stage individual participant data meta-analyses were performed based on 18 cohorts within the Psychosocial Factors and Cancer Incidence consortium that had a measure of depression or anxiety (N = 319 613, cancer incidence = 25 803). Health behaviors included smoking, physical inactivity, alcohol use, body mass index (BMI), sedentary behavior, and sleep duration and quality. In stage one, path-specific regression estimates were obtained in each cohort. In stage two, cohort-specific estimates were pooled using random-effects multivariate meta-analysis, and natural indirect effects (i.e. mediating effects) were calculated as hazard ratios (HRs).Results Smoking (HRs range 1.04-1.10) and physical inactivity (HRs range 1.01-1.02) significantly mediated the associations among depression, anxiety, and lung cancer. Smoking was also a mediator for smoking-related cancers (HRs range 1.03-1.06). There was mediation by health behaviors, especially smoking, physical inactivity, alcohol use, and a higher BMI, in the associations among depression, anxiety, and overall cancer or other types of cancer, but effects were small (HRs generally below 1.01).Conclusions Smoking constitutes a mediating pathway linking depression and anxiety to lung cancer and smoking-related cancers. Our findings underline the importance of smoking cessation interventions for persons with depression or anxiety.

BackgroundDepression and anxiety have long been hypothesized to be related to an increased cancer risk. Despite the great amount of research that has been conducted, findings are inconclusive. To provide a stronger basis for addressing the associations between depression, anxiety, and the incidence of various cancer types (overall, breast, lung, prostate, colorectal, alcohol-related, and smoking-related cancers), individual participant data (IPD) meta-analyses were performed within the Psychosocial Factors and Cancer Incidence (PSY-CA) consortium. MethodsThe PSY-CA consortium includes data from 18 cohorts with measures of depression or anxiety (up to N = 319,613; cancer incidences, 25,803; person-years of follow-up, 3,254,714). Both symptoms and a diagnosis of depression and anxiety were examined as predictors of future cancer risk. Two-stage IPD meta-analyses were run, first by using Cox regression models in each cohort (stage 1), and then by aggregating the results in random-effects meta-analyses (stage 2). ResultsNo associations were found between depression or anxiety and overall, breast, prostate, colorectal, and alcohol-related cancers. Depression and anxiety (symptoms and diagnoses) were associated with the incidence of lung cancer and smoking-related cancers (hazard ratios [HRs], 1.06-1.60). However, these associations were substantially attenuated when additionally adjusting for known risk factors including smoking, alcohol use, and body mass index (HRs, 1.04-1.23). ConclusionsDepression and anxiety are not related to increased risk for most cancer outcomes, except for lung and smoking-related cancers. This study shows that key covariates are likely to explain the relationship between depression, anxiety, and lung and smoking-related cancers. Preregistration number.

OBJECTIVE:Psycho-oncological institutions offer specialized care for cancer patients. Little is known how this care might impact fatigue. This study aimed to identify fatigue trajectories during psychological care, examined factors distinguishing these trajectories and predicted fatigue severity after nine months of psychological care.DESIGN:Naturalistic, longitudinal study of 238 cancer patients receiving psycho-oncological care in the Netherlands. Data were collected before initiation of psychological care (T1) and three (T2) and nine months (T3) afterwards. Latent class growth analysis, repeated measure analyses (RMA) and linear regression analysis were performed.MAIN OUTCOME MEASURES:Fatigue severity: Checklist Individual Strength.RESULTS:Three fatigue trajectories were identified: high- (30%), moderate- (62%) and low-level fatigue (8%). While statistically significant decreases in fatigue were found, this decrease was not clinically relevant. RMA showed main effects for time for fatigue trajectories on depression, anxiety, personal control and illness cognitions. Fatigue severity and physical symptoms at T1, but not demographic or clinical factors, were predictive of fatigue severity at T3.CONCLUSIONS:Fatigue is very common during psycho-oncological care, and notably not clinically improving. As symptoms of fatigue, depression, anxiety and physical symptoms often cluster, supplementary fatigue treatment should be considered when it is decided to treat other symptoms first.

Abstract Objectives Psychosocial factors have been hypothesized to increase the risk of cancer. This study aims (1) to test whether psychosocial factors (depression, anxiety, recent loss events, subjective social support, relationship status, general distress, and neuroticism) are associated with the incidence of any cancer (any, breast, lung, prostate, colorectal, smoking‐related, and alcohol‐related); (2) to test the interaction between psychosocial factors and factors related to cancer risk (smoking, alcohol use, weight, physical activity, sedentary behavior, sleep, age, sex, education, hormone replacement therapy, and menopausal status) with regard to the incidence of cancer; and (3) to test the mediating role of health behaviors (smoking, alcohol use, weight, physical activity, sedentary behavior, and sleep) in the relationship between psychosocial factors and the incidence of cancer. Methods The psychosocial factors and cancer incidence (PSY‐CA) consortium was established involving experts in the field of (psycho‐)oncology, methodology, and epidemiology. Using data collected in 18 cohorts (N = 617,355), a preplanned two‐stage individual participant data (IPD) meta‐analysis is proposed. Standardized analyses will be conducted on harmonized datasets for each cohort (stage 1), and meta‐analyses will be performed on the risk estimates (stage 2). Conclusion PSY‐CA aims to elucidate the relationship between psychosocial factors and cancer risk by addressing several shortcomings of prior meta‐analyses.

We published a meta-analysis to determine the longitudinal positive effect of religion or spirituality (R/S) on mental health. Forty-eight longitudinal studies were summarized (59 independent samples). The meta-analysis yielded a significant, but small overall effect size of r =.08. We concluded that there is evidence for a positive effect of R/S on mental health, but this effect is small. Our meta-analysis was recently criticized in this Journal by Koenig et al. Scientific debate is welcome, but we disagree with most of their comments. Our reply focusses on the following topics: Is the effect of R/S small? Might methodological issues underlie the small overall effect size? Randomized controlled studies, and change course and look elsewhere for more convincing results?

Spirituality can support the adjustment process of people with cancer, by forming a meaning system that supports understanding of the cause and implications of the experience and that provides coping strategies. The different ways in which spiritual meaning systems might fulfill these roles were examined among 20 people who were treated for cancer with curative intent. Narrative interviews were held on average 16 months after cancer diagnosis. The interviews were analyzed in a two-stage process, based on a holistic content approach. The first stage led to the identification of various roles and outcomes of the meaning system. The second stage involved a comparison of these roles and outcomes between previously defined types of meaning systems. The roles identified were discrepancy, legitimation and continuation. Legitimation was associated with the outcome of integration, whereas continuation was associated with an outcome of a positive outlook toward the future. Several differences were found between types of meaning systems, regarding the extent to which and ways in which these roles and outcomes occurred. This study underscores recommendations that healthcare professionals should be aware of the different ways in which the patient's previous beliefs and experiences influence their current adaptation to serious life events.

Objectives: This study aimed to identify predictors of returning to work in a group of cancer patients that sought and received help from mental health care institutes specialized in psycho-oncological therapy. Moreover we identified which psychosocial factors were seen as important for returning to work by these patients and therapists working at these institutes. Method: This naturalistic study focused on cancer patients who applied for help at specialized psycho-oncology institutions in the Netherlands. Data were collected before the start of psychological care (T1), and three (T2) and nine (T3) months thereafter. Predictors of return to work were identified based on the opinion of therapists and patients from psycho-oncology institutions in the Netherlands. Predictor scores at T1 were used to predict return to work at T3. Discrimination between patients with and without return to work at T3 was investigated with receiver operating characteristic (ROC) analysis and expressed as the area under the ROC curve (AUC). Results: At T1, 174 participants (79%) were off work due to sickness and 119 (68%) had returned to work at T3. Therapists and patients identified psychological symptoms, quality of life, comorbidity, helplessness, acceptation, mastery, stressful life-events, well-being, and domestic and social functioning as being important for predicting return to work. Domestic functioning was the strongest predictor of return to work at T3. The prediction model including all identified predictor variables did not discriminate between patients with and without return to work at T3, with AUC = 0.652 (95% CI 0.553–0.751). Conclusions: These results suggest that, although psychological symptoms are important at face validity for return to work after cancer, in patients that received help for psychological symptoms, they do not predict return to work.

AimsSpirituality can be important in adjusting to the experience of cancer and its medical treatment. Since nurses have frequent contact with patients, they seem to have a unique role in providing spiritual care. Nurses consider spiritual care important; however, little is known about how patients in a curative setting experience and value spiritual care. Therefore, this study aimed to give insight into patients’ experiences with and opinions about spiritual care as provided by nurses in curative cancer care.MethodsThis is a national, multicentre mixed‐methods study, combining a quantitative approach using questionnaires (n = 62) and a qualitative analysis of semi‐structured interviews (n = 61). Nonparametric tests were used for quantitative data, and qualitative data were analysed inductively.FindingsMost patients rarely received spiritual care by nurses. If spiritual care was provided, it mainly consisted of noticing problems and referring to other professionals. This appeared to be dependent on certain ‘triggers’, such as age. Structural discussions on spirituality with a nurse were experienced rarely. This was explained by, among other factors, the hospital setting. Yet, the majority (79%) of patients found the attention to spirituality sufficient or very good. Furthermore, a majority (58%) viewed spiritual care as a nursing task: nurses should notice spiritual problems and refer to other professionals, though extensively discussing patients’ spirituality was neither considered nurses’ task nor capability.ConclusionsAttention to spiritual care in a curative setting, though not so much desired by most patients, should be pursued, because of its importance in performing person‐centred nursing care and its positive impact on patients’ health. By training nurses in offering spiritual care in proactive and ‘nonactive’ (accepting) ways, spiritual care could be structurally offered in clinical practice in personalised forms. Since younger and less spiritual patients are not much satisfied with spiritual care by nurses, they need special attention.

Various authors in research on coping advise us to study spirituality from a meaning system perspective. In this approach spirituality is viewed as a part of people’s global meaning; an overarching framework of beliefs, goals, and sense of meaning. However, little is known about how spirituality is related to other global meanings to form this meaning system. Therefore, we have explored spirituality and its relationship with other possible elements of the meaning system in interviews with 20 persons, one year after their cancer diagnosis. Applying thematic analysis to analyze the interviews, a typology was developed based on two criteria: (a) the prevalence of spiritual meanings in the interview, and (b) the degree of co-occurrence between spiritual and general meanings. Four types of meaning systems were distinguished: (a) spirituality as an overarching theme that seems to infuse all aspects of the person’s meaning system, (b) spirituality as a theme in the background of the meaning system portrayed by a supporting God, (c) spirituality as a hidden theme that is expressed by a transcendent image and experience of oneself, or (d) spirituality as separate from other elements of the individual’s meaning system, if described at all. A comparison with quantitative measures of religiosity and spirituality supported the qualitative differences between the four types. This typology can be used to further understand individual differences in adjustment to cancer.

Rationale: When diagnosed with cancer, a patient has to cope with stressors such as pain, fatigue, and the experience of life-threat that can cause great distress. Spirituality may be a resource for coping with these problems, thereby reducing distress. Objective: Two questionnaire studies the first a cross-sectional (Study 1; N = 216) and the second a one-year longitudinal (Study 2; N = 383) investigated among Dutch cancer patients whether spirituality lessens the impact of pain, fatigue, and perceived life-threat on distress. Method: Data for Study 1 were gathered in 2006-2007 and for Study 2 in 2009-2010. Spirituality was measured with the Spiritual Attitude and Involvement List, which assesses six distinct but related aspects of spirituality. Linear regression analysis and marginal effect plots were applied. Results: Limited evidence appeared for the hypothesis that spirituality reduces the impact of pain, fatigue, or perceived life threat on distress. Meaningfulness and acceptance might reduce a negative impact of increases in fatigue during the rust year after the start of cancer treatment. In contrast, spirituality might enhance a negative impact of increases in perceived life threat. Conclusions: Processes of appraisal might explain the findings. Experiences of meaningfulness and acceptance might help to reappraise fatigue in a less threatening way, thereby reducing distress. Conversely, appraising the cancer as life-threatening might conflict with spiritual experiences of meaning, acceptance, and awe about life. Future studies should focus on the processes by which the various aspects of spirituality influence the adjustment of cancer patients and use other outcome variables than non-specific distress. Such studies may provide further clues as to how the spirituality of patients can be harnessed to help them adjust to a serious life event such as the occurrence of cancer.

This study aimed to (1) identify benefit finding trajectories in cancer patients receiving psychological care; (2) examine associations of benefit finding trajectories with levels of and changes in psychological symptoms; and (3) examine whether socio-demographic and medical characteristics distinguished trajectories. Naturalistic longitudinal study design. Participants were 241 cancer patients receiving psychological care at specialized psycho-oncological institutions in the Netherlands. Data were collected before starting psychological care, and three and 9 months thereafter. Latent class growth analysis was performed to identify benefit finding trajectories. Five benefit finding trajectories were identified: ‘high level-stable’ (8%), ‘very low level-small increase’ (16%), ‘low level-small increase’ (39%), ‘low level-large increase’ (9%), and ‘moderate level-stable’ (28%). People in distinct benefit finding trajectories reported significant differential courses of depression but not of anxiety symptoms. Compared with the other four trajectories, people in the ‘low level-large increase’ trajectory reported the largest decreases in depression over time. Perceptions of cancer prognosis distinguished these trajectories, such that people with a favourable prognosis were more likely to belong to the ‘high level-stable’ trajectory, while people perceiving an uncertain prognosis were more likely to belong to the ‘low level-large increase’ trajectory of benefit finding. Cancer patients showed distinct benefit finding trajectories during psychological care. A small proportion reporting a large increase in benefit finding were also most likely to show decreases in depressive symptoms over time. These findings suggest a relation between perceiving benefits from cancer experience and improved psychological functioning in cancer patients receiving psychological care. What is already known on this subject? What does this study add?

OBJECTIVES This study aimed to (1) identify benefit finding trajectories in cancer patients receiving psychological care; (2) examine associations of benefit finding trajectories with levels of and changes in psychological symptoms; and (3) examine whether socio-demographic and medical characteristics distinguished trajectories. DESIGN Naturalistic longitudinal study design. METHODS Participants were 241 cancer patients receiving psychological care at specialized psycho-oncological institutions in the Netherlands. Data were collected before starting psychological care, and three and 9 months thereafter. Latent class growth analysis was performed to identify benefit finding trajectories. RESULTS Five benefit finding trajectories were identified: 'high level-stable' (8%), 'very low level-small increase' (16%), 'low level-small increase' (39%), 'low level-large increase' (9%), and 'moderate level-stable' (28%). People in distinct benefit finding trajectories reported significant differential courses of depression but not of anxiety symptoms. Compared with the other four trajectories, people in the 'low level-large increase' trajectory reported the largest decreases in depression over time. Perceptions of cancer prognosis distinguished these trajectories, such that people with a favourable prognosis were more likely to belong to the 'high level-stable' trajectory, while people perceiving an uncertain prognosis were more likely to belong to the 'low level-large increase' trajectory of benefit finding. CONCLUSIONS Cancer patients showed distinct benefit finding trajectories during psychological care. A small proportion reporting a large increase in benefit finding were also most likely to show decreases in depressive symptoms over time. These findings suggest a relation between perceiving benefits from cancer experience and improved psychological functioning in cancer patients receiving psychological care. Statement of contribution What is already known on this subject? People vary in course of benefit finding (BF) after trauma, with some experiencing enhanced BF and others decreased BF. Empirical studies have identified subgroups of cancer patients with distinct BF trajectories. What does this study add? This is the first study showing that cancer patients followed different BF trajectories during psychological care. Only a small proportion experienced clinically meaningful increases in BF over time. More attention is needed for cancer patients with decreased BF, as they are at a higher risk of remaining depressed.

Abstract Measures of spirituality often contain the dimension existential well-being (EWB). However, EWB has been found to overlap with emotional and psychological well-being. Using the Spiritual Attitude and Involvement List (SAIL), we have further investigated the overlap between aspects of spirituality and of well-being among patients with cancer, by determining a) the divergent validity of the subscales of the SAIL compared with a well-being questionnaire and b) the differences in their associations to changes in pain and fatigue, and the occurrence of negative life events. Our findings suggest that a sense of trust that one is able to cope with difficulties of life belongs to the realm of well-being, instead of spirituality. Other aspects, such as a sense of meaning in life, seem more similar to spirituality than to well-being. These results can bring researchers a step further toward constructing “pure” spirituality and well-being measures, which will allow them to investigate the (causal) relationship between these constructs.

Measures of spirituality often contain the dimension existential well-being (EWB). However, EWB has been found to overlap with emotional and psychological well-being. Using the Spiritual Attitude and Involvement List (SAIL), we have further investigated the overlap between aspects of spirituality and of well-being among patients with cancer, by determining a) the divergent validity of the subscales of the SAIL compared with a well-being questionnaire and b) the differences in their associations to changes in pain and fatigue, and the occurrence of negative life events. Our findings suggest that a sense of trust that one is able to cope with difficulties of life belongs to the realm of well-being, instead of spirituality. Other aspects, such as a sense of meaning in life, seem more similar to spirituality than to well-being. These results can bring researchers a step further toward constructing "pure" spirituality and well-being measures, which will allow them to investigate the (causal) relationship between these constructs.

Aim: To gain insight into the quantity and quality of spiritual care provided by nurses in curative cancer care, from the perspectives of both patients and nurses.Background: Cancer causes patients to suffer from diverse symptoms related to their illness. Nurses play an important role in the care for people with cancer. Next to paying attention to physical and psychosocial needs, caring for spiritual needs of patients also belongs to good nursing. Most of the research concerning spirituality and spiritual care in relation to cancer has focused on palliative care.Design: A mixed methods design will be used in two sub-phases. First, we will conduct semi-structured interviews with 72-90 patients coming from nine hospitals. Subsequently, approximately the same number of nurses working on oncology wards of these hospitals will be interviewed.Methods: We meticulously composed both interview guides so that only near the end of the interview explicit terms like spirituality and spiritual care are explicitly mentioned. Until that point, we will use other words to define the concepts. Next to the interviews, demographics, answers to some statements and several questionnaires will be gathered. Content analysis supported by DEDOOSE will be used to answer the research questions.Discussion: The insight we will gain in this study enables us to compare experiences from the perspective of both patients and nurses. This can also provide us with suggestions for the improvement of nursing care for people with cancer who are treated with curative intent, a topic until now hardly addressed.

Spirituality may help people to maintain a high level of well-being despite adversity, but several studies that claim to support this statement have used spirituality scales and outcome measures that have overlapping content. This practice seems to be widespread: In an exploratory survey of 8 well-cited journals we found that 26 of 58 studies used a spirituality scale that contains 25% or more of well-being items to examine whether spirituality predicts well-being or distress. These spirituality questionnaires would be more appropriate for use as indicators of the domain of quality of life called spiritual well-being. We urge researchers to only use spirituality questionnaires of which less than 25% of the items refer to emotional well-being-such as the SWB Questionnaire or the Spiritual Attitude and Involvement List-when investigating the causal relationship between spirituality and emotional well-being.

Quantitative studies have assessed nurses' attitudes toward and frequency of spiritual care [SC] and which factors are of influence on this attitude and frequency. However, we had doubts about the construct validity of the scales used in these studies. Our objective was to evaluate scales measuring nursing SC. Articles about the development and psychometric evaluation of SC scales have been identified, using, Web of Science, and CINAHL, and evaluated with respect to the psychometric properties and item content of the scales. Item content was evaluated by each of the five authors with respect to the following questions: Does the item (1) reflect a general opinion about SC instead of a personal willingness to offer SC; (2) reflect general psychosocial care instead of specific SC; (3) focus solely on religious care; (4) contain the words spiritual' (care/needs/health/strengths, etc.); and (5) contain multiple propositions, or have an unclear meaning? We found eight scales. Psychometric analysis of these scales was often meager and the items of all but one scale suffered from two or more of the five problems described above. This leads us to conclude that many quantitative results in this area are based on findings with questionable scales. Suggestions for improvements are provided.