Int J Gynecol Cancer 2004, 14, 183—201

REVIEW ARTICLE

Spirituality in gynecological oncology: a review

L. M. RAMONDETTA* & D. SILLS†
*Department of Gynecologic Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, TX; and
†Department of Religion, California Lutheran University, Santa Barbara, CA

Abstract. Ramondetta LM, Sills D. Spirituality in gynecological oncology:

a review. Int J Gynecol Cancer 2004;14:183—201.

The following is a review of some of the work that has been published
on issues related to definitions of spirituality and the many ways in
which religious or spiritual concerns inform and can sometimes mold
the relationships between gynecologic oncology patients, their physi-
cians, and their health. Moreover, we have raised the question whether
there is something specific or unique to the experience of women
patients with reproductive cancers? Although it might seem clear to
many of us that these patients are unique, it is hard to say exactly
why. While there are differences between the various types of repro-
ductive cancers, all share a common thread and all undermine the
patient’s identity as a woman. For oncologists, exploring the connection
between the healing of the body and the healing of the spirit recognizes
the comprehensive character of cancer treatment, and furthers the
understanding that both physicians and patients share a knowledge
that what patients lose in their battle with cancer is more than simply
a medical life.

KEYWORDS: spirituality, gynecologic oncology, women’s studies, religion.

It is with a sense of irony that we begin this review
article of recent work on spirituality and women’s
reproductive cancers. Up until the last 20 years, a
diagnosis of cancer of virtually any kind was heard
by the patient and his or her family as a terminal
sentence. With advances in cancer biology and treat-
ment options, the lives of cancer patients have been
prolonged, and in some cases, cancer can be treated
like diabetes, a chronic disease that requires monitor-
ing and, at times, further regular treatments. What is
ironic is that, in the face of improved patient out-
comes, researchers and physicians, particularly in
Address correspondence and reprint requests to: Lois
M. Ramondetta, MD, Department of Gynecologic Oncology, Unit
440, The University of Texas M. D. Anderson Cancer Center,
1515 Holcombe Boulevard, Houston, TX 77030-4009, USA.
Email: lramonde@mdanderson.org
# 2004 IGCS
the field of women’s reproductive oncology, have
turned their attention to issues relating to women’s
spirituality and the ways in which religious or spirit-
ual concerns inform and can sometimes shape the
relationships between gynecologic patients, physi-
cians, and nurses.
We have been asked to review some of the work
that has recently been published on issues related to
definitions of spirituality and the many ways in
which religious or spiritual concerns inform and can
sometimes mold the relationships between gyneco-
logic oncology patients, their physicians, and their
healthcare providers. Moreover, we have raised the
question whether there is something specific or
unique to the experience of women patients with
reproductive cancers? Alternatively, one can ask
whether the experience of treating women with repro-
ductive cancers is somehow exceptional for phys-
icians and medical personnel? Although it might
184 L. M. Ramondetta & D. Sills
seem clear to many of us that these patients are
unique, it is hard to say exactly why. One research
nurse at M. D. Anderson Cancer Center may have put
it just right. ‘It’s simple’ she said, ‘they are all our
mothers.’ From her point of view, regardless of the
gender of the physician, the relationship with the
gynecologic oncology patient takes on a deeper and
more intimate character. Furthermore, for female phys-
icians and nurses, psychologically, this idea easily
morphs into recognition that the reproductive cancer
patients are our mothers, our sisters, and finally, our-
selves. But there may be more here. Reproductive
cancers attack the biological source of women’s iden-
tity and the source of her ability to reproduce life.
While there are differences between the various
types of reproductive cancers, all share a common
thread and all undermine the patient’s identity as a
woman. In ovarian cancer, the women are our
mothers, our sisters, and ourselves. These are often
women who have postponed childbearing, like so
many professional women we know and are and
have achieved a modicum of success in the public
world. This ‘silent killer’ attacks women just at the
point when they should be enjoying their success.
Moreover, because of its association with a specific
ethnicity and the likelihood that it will find its way
into the next generation of women, it carries with it
familial repercussions and a legacy of fear.
Vulvar cancer deforms the reproductive organs.
Repeated pelvic examinations, for what are often
modest, older women, serve as a source for their
continued humiliation and embarrassment. The removal
of the clitoris, sometimes the required treatment,
again reinforces the sense of loss and mutilation.
Cervix cancer patients, often younger than ovarian
and vulvar patients, have cancer at ‘la bocca de la
martrise.’ The association of cervix cancer with sexu-
ally transmitted disease, premarital sex, or multiple
partners can foster an ongoing sense of guilt, shame,
and anger in patients.
Endometrial cancer is literally cancer of the womb,
the ‘maqor’-source of life and the ‘maayan’-spring of
life and blood in Hebrew, the place of origin of the
fetus. In China, the uterus has been equated with the
source of bodily energy, the ‘chi.’ Hysterectomy thus
weakens the energy flow that cleanses the body(1).
While these cancers pose biological problems for
physicians and patients alike, the cultural meanings
that are associated with women’s reproductive organs
and their corruption carry with them mythic and
spiritual implications. In Sophocles’ Oedipus Rex,
the Gods curse Oedipus and his kingdom with a
plague of a peculiar sort. Neither women nor animals
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
can bring forth life, all species are barren(2). The
drama of the Patriarchs in the Hebrew Bible is really
a drama about childbearing. The Abraham narrative
hinges on Sari/Sarah’s inability to bear a child until
God intervenes when she is a 90-year-old woman, at
which point she gives birth to a son aptly named
Isaac, ie, ‘to laugh’ in Hebrew. In Indian tradition,
the Hindu blessing, ‘may you be the mother of 100
sons’, reflects both the value placed on sons in an
agricultural community and the necessity of marriage
and childbearing for Indian women’s collective sense
of identity. As oncologists who treat reproductive
cancers, we are all too familiar with how difficult
these diseases are for our patients, both physically
and emotionally and, finally, spiritually.
Simon de Beauviour may have been right when she
argued that ‘women are not born, they are made.’(3)
Humanists and social scientists recognize that the
nature of male and female identity as well as our
responses to illness in general, and to cancer in parti-
cular, are to a very large extent reflections of the social
and cultural values of our life and times. One’s chromo-
somal sex is usually a given, but what it means, or
to use Carolyn Bynum’s phrase, ‘how it means’, is an
important issue for those who treat women with
reproductive cancers(4). Specifically, do issues that
now fall under the category of ‘human spirituality’
take on a different cast when the cohort under treat-
ment is exclusively female? Do women experience
end-of-life issues differently than men? This may be
a new question in oncology circles, but it has been
under consideration for several years among Ameri-
can and European anthropologists and students of
religion. Anthropologist Susan Starr Sered makes an
interesting argument in her Priestess Mother Sacred
Sister: Religions Dominated by Women about the pecu-
liar character of women’s religious experience(5).
Sered begins her study by asking whether women’s
religions are in anyway ‘womanly?’ Her survey of the
Burmese Nat Religion, the Black Caribs of Belize,
Christian Scientists, and the American Shaker Com-
munity as well as 20th Century Afro-Brazilian reli-
gion, the Sande cults of Sierra Leone, and the
Feminist Spirituality traditions of the United States
all suggest to her that the ‘this worldly’ orientation
of female-dominated religions is what distinguishes
them from other religious communities. Specifically,
Sered argues that it is the trans-national character of
women’s emotional and practical experience of
mothering that is the common thread that ties these
varied religious traditions together. Sered finds that
virtually all women-dominated religions reflect women’s
social role as mothers in societies in which role is
 Spirituality, religion, and gynecological oncology
granted both esteem and structurally recognized
authority. Sered writes that ‘what does receive
attention and elaboration is women’s social roles as
nurturers and healers, women’s primary role as child-
care providers, women’s experience of pain at the
illness and death of children, and women’s proclivity
for discovering the sacred which is immanent in the
everyday world of care and relationships.’ This is not
to suggest that these patterns are unique to women’s
religions, rather Sered writes, ‘they are just easier to
see in women’s religions. . . and I surmise that many
of these patterns can also be found in women’s
religious activities within male-dominated religions.’
What differs is the degree to which women’s concern
for the health and safety of families, reflecting
communal ‘strategies for living’ are institutionalized
and esteemed in women’s traditions.
Contemporary medical literature supports the
importance of spirituality for patients generally and
for women specifically(6—9). Pargament has shown that
women displayed higher religiosity than men and
appear to be more likely to reap the benefits of living
a religious life(10). Others have also demonstrated that
women appear to be more religiously focussed than
men, often using religion to cope with illness(11,12).
Women not only are more likely to exhibit extrinsic
religious behavior but they also report significantly
higher levels of intrinsic religiosity(13,14).
The medical literature has considered issues related
to human spirituality from a number of different
perspectives. We have chosen to focus on the impact
of religion and spiritual concerns in terms of (1)
improved coping skills, (2) improved physician—
patient communication, (3) various methods to assess
spiritual history in a medical setting, (4) possible bet-
ter health outcomes and therapeutic spiritual inter-
ventions, and finally, (5) the immeasurable personal
benefits for healthcare providers.
Defining spirituality and religion
Definitions of religion run from EB Tylor’s ‘belief in
spiritual beings’ to Rudolf Otto’s ‘idea of the holy.’(15,16)
What makes discussions of the impact of religion on
patients’ lives so difficult for research physicians is
the requirement to translate ideas about human spir-
ituality into research protocols. As one author put it,
‘how does one measure a sunbeam?’(17) Puchalski(18)
describes spirituality as ‘the intangible mysteries of
life and the quality of our relationships with our-
selves, others, and God.’ But he goes on that ‘it can
also be about nature, art, music, family, or community
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
185
(essentially), whatever beliefs give a person a sense of
meaning and purpose in life.’ In 1571, Ferencz
David(19) stated, ‘the most important spiritual func-
tion is conscience, the source of all spiritual joy and
happiness.’ In 1971, the White House Council on
Aging(20) defined spiritual concerns as ‘the human
need to deal with sociocultural deprivation, anxieties
and fears, death and dying, personality integration,
self-image, personal dignity, social alienation, and
philosophy of life.’ Even the National Cancer Institute
recognized the need to define spirituality, suggesting
that ‘Spirituality is generally recognized as encom-
passing experiential aspects, whether related to
engaging in these practices or to a general sense of
peace and connectedness.’(21) We often think of religion
institutionally, as an organization that provides a
framework, both theological and communal, and that
will provide answers to spiritual questions through
a specific set of beliefs and practices. What then is
the intersection between religion and medicine?
Barnes(22) argues, ‘Spirituality and religion intersect
with medicine at the juncture of suffering.’ His obser-
vations are not far from anthropologist Clifford
Geertz’ suggestions that what religions do, transcul-
turally, is to ‘make suffering sufferable.’(23) We might
want to ask whether there is something specific to the
cancer experience that forces individuals, male and
female, to contemplate the existential and to deal
with the meaning of one’s life more forcefully than
those who suffer from other diseases or who consti-
tute what oncologist Julie Taguchi(24) has called ‘the
worried well.’ Reed’s(25) research suggests that indeed
the terminally ill have a greater spiritual perspective
than non-terminally ill individuals.
In 1969—70, the field of Gynecologic Oncology came
into its own when the American Board of Obstetrics
and Gynecologic recognized Gynecologic Oncology
as a certified subspecialty, and subsequently, received
its first certification in 1973. According to the Ameri-
can Women’s Medical Association, before the 1970s,
women constituted approximately 6% of medical stu-
dents and practicing physicians(26). Beginning in the
late 1960s and encouraged by the passage of the Equal
Opportunity Act of 1970, more and more women
entered medical school and other professional gradu-
ate programs. Women now constitute about half of all
medical students and over half of all students who are
training for the ministry. To return to Susan Starr
Sered’s point, women who have historically been
responsible for the care and oversight of their families
and their children are by definition in the ‘healing
trades.’(5) Historically, women have brought children
into the world, cared for them at home when they are
186 L. M. Ramondetta & D. Sills
sick, and have tried to ease the passage for those
under their care as they depart this life. It should
not be surprising to us that ‘the healing trades’ are
the sites for women’s entrance into American profes-
sional life. Theologian Rosemary Radford Ruether(27)
has suggested that, historically, women have viewed
religion differently than men. Women see religion,
according to Reuther, as a way to connect emotion-
ally to others and to heal, rather than to order
human experience hierarchically or to theorize on the
nature of the divine/human encounter. Historically,
woman’s spirituality expresses itself in terms of inter-
human relationships. Moreover, given the sexual seg-
regation of many patriarchal religious traditions,
women’s religious lives were lived primarily in pri-
vate, at home, and away from public male-dominated
religious rites. This in turn, Ruether concludes, may
have resulted in women developing a more intense
interpersonal dimension to their spirituality than men
have demonstrated. Clearly, this is important as
women face decisions related to cancer and terminal
disease.
Coping
Pargament et al.(28) have suggested that there are three
distinctly religious ways that patients deal with their
illnesses: (1) some develop a collaborative coping
style that involves what patients describe as an active
exchange with their God, (2) others approach decision
making more passively using their spirituality to
defer making choices, and (3) there are those who
see themselves as self-directed, problem solvers. Par-
gament argues that the collaborative and passive
styles of coping are associated with higher levels
of psychological well being. This is in contrast to
Holland(29) who suggests that active coping styles
are preferred. Following this line of argument, Walsh
et al.(30) claim that patients and families without spirit-
ual belief systems cannot resolve their grief as easily
as those whose worldview is shaped by religious
belief. Physicians know that some patients have a
more difficult time coping with their disease than
others do and including issues related to a patient’s
religious beliefs and practices at the point of diagnosis
might help healthcare providers identify those individ-
uals who need more help.
Many patient-based studies show that religious
affiliation can help patients cope with terminal dis-
ease(12,31—33). Specifically with the diagnoses of
cancer, patients are confronted with a biologic and
existential crisis(29). Patient’s religious worldviews
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
can often provide a set of moral value, and a model
for behavior, which can in turn enable them to experi-
ence the ‘innate deep desire to give as much meaning
as possible to our life, to actualize as many values as
possible.’(34)
McMillmuray et al.(35) attempted to assess the psy-
chosocial and spiritual needs of cancer patients. Of
these patients, 83% said that they had religious faith,
and in general, these patients were less reliant on
health professionals, had less need for health informa-
tion, attached less importance to the maintenance of
independence, and had less need for help with feel-
ings of guilt than those who said that they had no
religious faith. A greater proportion of patients with
unmet needs were found among those with no reli-
gious faith. Given these statistics, one might ask
whether ‘believers’ are more accepting and resigned
to their disease (fatalistic) than non-believers? Could
this also indicate that ‘having faith’ could actually
cause a problem for patient compliance with treat-
ment regiment in certain communities? This is a
very difficult question and is currently the focus of a
great deal of research.
The 2003 study by McMillmuray’s group used a
validated questionnaire which asked patients ‘do
you have religious faith?’(35) What this question fails
to recognize is that ‘having religious faith’ is not an
absolute category. Being ‘religious’ invokes a multi-
level sense of identity. More immediately, the ques-
tion itself defies practical measurability. Furthermore,
this study may not have included balanced popula-
tions equally representing the four coping styles out-
lined by Pargament(28).
Religion may help patients cope by providing an
active framework to face existential crisis(29). Holland
et al. studied 117 melanoma patients using the Sys-
tems of Belief Inventory (SBI). Although no correl-
ation was seen between SBI score and level of distress,
she found that those with more spiritual religious
beliefs used more active cognitive coping styles. This
is contrary to McMillmuray’s findings and suggests
that a more complex relationship exists between faith,
coping styles, and a patient’s sense of well being. It is
important to note that all the patients in Holland’s
study were white, mostly married, and well educated.
This study was also limited to primarily Catholic,
Jewish, and Protestant patients, and even the authors
acknowledge that their findings cannot be applied
more generally.
Religion may be a coping mechanism, which helps
individuals to overcome their isolation. ‘Human
suffering becomes bearable when we share it. The
patients who are worst off are those who die alone,
 Spirituality, religion, and gynecological oncology
those who are next worst off are those who aren’t
literally alone, but who feel alone.’(36) Religion may
help individuals feel loved and cared for and give
them some sense of control, even when they are
alone(36,37). Illness and the crisis of dying force us
to recognize our singularity and separateness. For
some, religious belief unites the body and mind, and
this sense of wholeness can have a calming effect.
MacPhee (38) concentrates on the imagined role of
the heart in producing harmony and good feeling in
Morrocan, Muslim women. Paraphrasing a few Mus-
lim women, MacPhee writes, ‘True healing requires a
calm heart.’ She goes on to situate the notion of a
‘calm heart’ within the larger framework of Muslim
culture, arguing ‘Even when the lure of individualism
jeopardizes social security, mindful prayer surrounds
the performer within a harmonious space that pro-
tects her from the unpredictable world and reduces
fears of being alone.’(38)
A religious and spiritual worldview may help
patients maintain a sense of hope for survival(39,40).
In one survey, 93% of patients with cancer said that
religion helped sustain their hopes for the future(41).
Interestingly, while only one-third of men surveyed
gave religious responses to open-ended questions,
two-thirds of older women gave religious responses
to open-ended questions about how they coped with
the worst aspects of their disease(42). In a survey of
admitted medical patients in 1998, 40% cited religion
as the single most important factor in their ability to
cope with their illness. Clearly, for many of our
patients, and particularly for our female patients,
some form of spirituality is part of their armament-
arium, as they battle their personal war against
cancer.
What these articles demonstrate is the impact that a
patient’s religious worldview can have on his or her
mode of coping with illness. Religious belief and
practice may not always be salutary. In cases where
patients can imagine the course of their lives as essen-
tially under their own control, a diagnosis of cancer
can be devastating, perhaps more devastating than for
those who imagine themselves and their destiny ‘in
God’s hands.’ In other words, recognizing that ‘God,
who has a plan for us all’ is in control and not an
imperfect ‘physician’ may be comforting to those who
feel their control over their own lives is limited. What
other researchers have recognized is that lack of spir-
itual well being correlates with end of life despair,
even more strongly with patients who exhibit depres-
sive symptoms(43). What is still unclear is whether
intervening with some degree and form of spiritual
support would help alleviate this despair.
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
187
Satisfaction with health care and quality-
of-life
A woman in her fifties, reflecting on her cancer care,
suggested that if things go badly, patients have ‘a
very short and very intense relationship with their
oncologists’ or if things go well, they have ‘a longer
and very intense relationship with their oncologists.’
Clearly, oncology is not automotive medicine.
Patients don’t leave their bodies and return to pick
them up at 5 o’clock. Undergoing cancer treatment
requires a good deal of grit, and at points, courage,
and invariably, patients look to their doctors and
nurses as their healers and their counselors.
At the same time, academic oncologists and clinical
care personnel approach issues related to cancer treat-
ment and end of life issues differently than their
patients. Available research suggests that a patient’s
spirituality is an important component of quality-of-
life (QOL)(44,45). Moreover, surveys have shown that
the majority of patients throughout the world want
their physicians to ask about spirituality during med-
ical assessments(46,47). The question about the advis-
ability of discussing patients’ religious concerns is
clearly an important one and may affect the level of
patients’ satisfaction, their sense of being able to make
an informed decision regarding their care and treat-
ment, and finally, the degree to which patients’
families and physicians can speak of their death as
‘a good death.’(48)
People express their religious orientations differ-
ently. Available research suggests that a patient’s cul-
tural traditions, family history, socioeconomic status,
and gender all serve to shape his or her religious
values. For example, the importance of religion in
the lives of cancer patients appears to be significantly
different in certain minority populations. African
Americans seem to have a stronger degree of religio-
sity, to express more deeply felt spiritual needs, and
are more likely to use healing practices from religio-
sity compared to White populations(11). This expressive
religiosity may improve care by bringing a greater
intensity and intimacy to the physician—patient rela-
tionship. This intensified relationship may be particu-
larly important for minority populations that have
registered difficulty in trusting the medical establish-
ment(48,49). ‘The intersection of spirituality or religi-
osity and health for ethnic women of color can make a
difference in their health experience, helping to elim-
inate health disparities and promoting positive health
outcomes.’(50)
Emerging oncologic research into questions about
spirituality may reflect patients increasing willingness
188 L. M. Ramondetta & D. Sills
to engage their physicians in a deeply human rela-
tionship. While religion was for many years a ‘private
matter’, it has now become increasingly part of our
public discourse. Films ranging from ‘Dogma’ to
‘What Dreams May Come’ reflect our increasing
ease in addressing the once private issues of our
interior religious lives. How much the more so as
cancer patients face their own mortality and the pecu-
liar character of the cancer journey itself.
Recognizing the importance of spiritual values in
the lives of our patients will enable us to help them
maintain a sense of human coherence and meaning in
the face of their medical experience. This problem is
illustrated by the findings of a study of Muslim
colostomy patients in Turkey(51). Feelings regarding
the outcomes of anterior perineal resections versus
sphincter-saving surgeries were compared in Muslim
patients. Praying and fasting were impaired in
patients who had stomas. Many of the patients
stopped praying daily and stopped fasting during
Ramadan, which they suggested reflected issues
related to cleanliness, even when Shariah made
allowances for situations of this sort. These life-
changing surgeries, in many cases, led to patients’
social isolation(51). Perhaps if physicians had pre-
operative discussions with their patients about the
details of stoma function and care, patients would
have been better prepared and better able to make
informed decisions about their continued care
and treatment. Alternatively, in the case of an
unavoidable colostomy, patients could secure
counseling to help them avoid the anxiety and social
isolation that sometimes follows on a surgery of this
sort.
Even more important may be the role faith plays
in medical decision making. Addressing this issue,
Silvestri et al.(52) considered the responses of 100 patients
and caregivers as well as 257 oncologists. For newly
diagnosed lung cancer patients and caregivers, faith
in God ranked second only to recommendations of
the medical oncologist as the factor most important in
their medical decision making. Alternatively, phys-
icians thought faith in God should be the least import-
ant factor in medical decision making. In this study, a
higher ranking of faith correlated with a lower level of
education. This may be an aspect of how religion
identifies an internal locus of control for those
patients who may not understand technical aspects
of their treatment options(52).
A 1997 telephone survey used a multidimensional
conception of religious faith in healing(53). Of the 1052
participants, 43% were Baptist, 12% were Methodist,
13% other Protestant denominations, and 6% Catholics.
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
The survey explored issues relating to belief in
miracles, belief in religious healers, the power of
God’s will to heal, and the idea that God acts through
physicians and medical personnel. This project led to
the design of the spiritual faith in healing index.
Responses were compared across race, gender, educa-
tion, income, and health. Eighty percent believed that
God acts through physicians to cure illness (these
responders were more likely African Americans and
older than 55) and 40% believed that God’s will is the
most important factor in recovery; spiritual faith in
healing was stronger among women, African Ameri-
cans, and evangelical Protestants of both genders as
well as poorer, sicker, and less educated patients gen-
erally. Those who discussed spiritual concerns with
physicians were more likely to be female and/or in
poor health. Although 69% of respondents said that
they wanted to speak to someone about spiritual con-
cerns, if they were seriously ill, only 3% would choose
to speak to their physician. The survey did not
address this disparity. The authors did suggest that
perhaps patients did not think that their physician
would understand the importance of their religious
belief to them. Another hypothesis argued that
patients had learned not to expect that spiritual issues
would be raised in a medical setting(53). A major limit-
ing factor of this study was the fact that the survey
was conducted in the American South, what research-
ers call the ‘Bible Belt’, and will not reflect the beliefs
and attitudes of those living in other regions of United
States, much less the world. However, in this popula-
tion, an inverse relationship was found between spirit-
ual faith in healing and levels of education. Religious
faith in healing is strongest among the poor. One
might ask whether this is because the studied popula-
tion has the least ‘faith’ in physician healing or access
to good medical care. and if this is the case, could we
lessen health disparities by supporting an individ-
ual’s faith-based beliefs?
This study supports the inclusion of spirituality
issues in the biophsycosocial QOL model. To begin
with, many patients believe God acts through their
physicians. Furthermore, they believe God’s will may
be even more important then the skills of their phys-
icians. and finally, most patients want to discuss spirit-
ual concerns when they are ill. It is clear that patients
use faith systems or religion to help them cope with
disease(33,54).
Surprisingly, little has been published in the field of
gynecologic oncology on spirituality and cancer. The
seven articles include Roberts et al. (1997) survey of
108 women with gynecologic cancers, which con-
firmed that religion had an important role in the
 Spirituality, religion, and gynecological oncology
lives of these patients(55). Of those surveyed, 76% said
that religion had a serious place in their lives and 49%
described themselves as more religious, since their
diagnosis. No women characterized themselves as
less religious either after their diagnosis or during
the course of treatment. Ninety-three percent believed
that their religious commitment sustained their hopes
for the future. This survey, although only an initial
step towards recognizing the importance of religious
belief in gynecologic oncology patients, did not use a
validated questionnaire and was restricted to a very
limited population. Ninety-seven percent of the
women were Christian and 3% were Jewish. The
authors concluded that the women’s religious com-
mitment was an important factor in enabling these
women to cope with their disease. The authors went
on to suggest that it could prove helpful and appro-
priate to include a member of clergy on a woman’s
health care team(55).
Donovan et al.(56) evaluated ovarian cancer patients’
treatment preferences, specifically looking at prefer-
ence for salvage therapy versus palliative care. They
found that decisions were not related to marital sta-
tus, number of children, or employment status. Can-
cer patients preferred salvage therapy in comparison
to non-cancer patients. The ‘switch point’ toward pal-
liative care was sooner for non-cancer patients and
was not related to spiritual well being as assessed by
FACT-SP and the SBI. This survey, as with others we
evaluated, was limited in its application to patients
who were Protestant Christians(56).
Chan et al.(57) surveyed 74 gynecologic oncology
patients in China for the purpose of identifying risk
factors of maladjustment in cancer survivors. These
authors found that increased religious belief correl-
ated with better family support and more significant
improvement in the degree of social activity. Patients
at risk for poor adjustment included those who were
treated surgically, those less educated, and those
without religious belief. This is a noteworthy point.
Other surveys conducted in the United States have
suggested that a patient’s degree of religiosity corre-
lated with less education. Clearly, patient’s cultural
orientation, SES, and education inform her willing-
ness to utilize religion as a coping mechanism. In
this study, only 60% reported participating in ‘some
religion’ and 40% ‘without participation in any reli-
gion.’ Those surveyed included 11 Catholics, 10 Chris-
tians, 14 Buddhist, and 10 ‘other.’ Medically, 67%
were cervix cancer patients or patients with gesta-
tional trophoblastic disease, a group that is consist-
ently younger than the rest of the gynecologic
cancer patients and possibly different from other
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
189
patients in their attitudes toward their disease and
level of existential crisis(57).
Alternatively, another study from China(1) sug-
gested that patients’ positive appraisal of the support
they felt during their treatment was linked to the
Chinese cultural values placed on food, a strong
work ethic, and the worldview associated with the
Confucian religious philosophy. Developmental the-
ories suggested that the role of human relationships
and human attachments are regarded as uniquely
significant in Chinese women’s lives and are directly
related to the source and the nature of the social
support women can avail themselves, as they cope
with the diagnosis and treatment of cancer. In this
separate survey of 18 women, which included only
Chinese Catholics and Buddhist, patients reported
that they were able to cope with illness by accepting
what they thought was God’s will or by what they
understood to be a causal relationship with the divine
that transcended the merely human(1). The patients
found inner peace by ‘handing themselves over to
God’ or to what they understood to be ‘fate.’ This
seemingly passive method of coping led patients to
report that their religious beliefs helped them to live
active and purposeful lives, despite their suffering.
This survey, like many others, did not use validated
questionnaires.
Using the spiritual well being scale, Gioiella et al.(58)
evaluated 18 female patients with gynecologic cancers
and reported that better QOL was associated with a
higher degree of spiritual existential and religious
well being. It is interesting that the patients in this
study who were older, married, and Catholic were
found to have higher degrees of spiritual well being.
This survey, like the others, lacked religious, eco-
nomic, and racial diversity. Of the 18 surveyed, 11
were catholic, 7 described themselves as religiously
‘other’, 11 had a college level education, 7 completed
high school or less, and 94% were white. No African
Americans participated. This survey included 11
patients with ovarian cancer, 2 with cervix cancer,
and 3 with endometrial cancer(58).
In another non-validated survey, Stewart et al.(59)
evaluated 200 survivors of ovarian cancer. The results
of this survey suggested that survivors believed that a
positive attitude kept them in remission (82.5%) and
that positive attitude was closely followed in level of
importance by healthy lifestyle, prayer, stress reduc-
tion, diet, and exercise. Apart from personal prayer,
spirituality was not specifically evaluated. In a Cana-
dian qualitative study (n ¼ 9) addressed to women
living with ovarian cancer, who by definition are
wrestling with the disease and the inevitability
190 L. M. Ramondetta & D. Sills
of what they imagine to be an early death, these
women did not ‘state that spirituality was integral in
helping them to deal with an early death.’ It actually
depended on whether religion was already a coping
strategy in their lives(60).
What all these studies share is a static and norma-
tive view of religion. What they fail to recognize is
the symbolic character of religious belief and practice
and the ways in which even members of the same
religious community will not necessarily interpret
religious dogma or prescribed practice in the same
way. Anthropologist Clifford Geertz’s(23) way of under-
standing religion as providing individuals with a
worldview and a set of ethics that are appropriate to
one’s metaphysics assumes that religion is part of a
larger cultural system of meanings. and more import-
antly, following the argument made famous by phil-
osopher Suzanne Langer(61) that making meanings is
what people do and what they can’t bear are the
existential dilemmas posed by what theologians
have called the problem of evil, theodicy, or the prob-
lem of suffering, or finally, the abyss that opens
when all human meaning is lost. Why this is import-
ant for health care professionals and for oncologic
physicians, in particular, is that the Geertzian per-
spective enables them to both acknowledge issues of
cultural and religious diversity and at the same time
to see the ways in which all patients, when confronted
with a cancer diagnosis, are grappling with existential
problems of meaning that often find expression in
religious or spiritual language. When Dr Von Eschenbach,
Director of the National Cancer Institute asks, ‘How
do we know what we don’t know we don’t know?’ He
is beginning to wrestle with the dilemma posed to
physicians by these metaphysical problems(62).
The issues that follow from Von Eschenbach’s ques-
tion are no less significant. In fact, in the context of the
physician—patient relationship, neither the patient nor
the physician may be able to answer them. But
answering the question may be beside the point. It
could be that it is the fact of the conversation that
matters. At the same time, in research protocols that
address the linkages between spirituality and health,
assembling the right group of patients to ask may
prove to be helpful indeed. It is important for those
interested in the intersection between spirituality and
cancer care to recognize that cultural diversity brings
with it a host of other issues, issues that are transcul-
tural and finally global. Again turning to Geertz, some
years ago he argued, ‘foreignness no longer starts
at the water’s edge but now at the skin’s edge.’(23)
Historian of global religions Mark Jugermeyer(63)
makes a similar point. He no longer maps the world
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
according to what had previously been described as
the ‘world’s big six religions: Judaism, Christianity,
Islam, Hinduism, Buddhism, and Confucianism.’ For
Jugermeyer(63), it is much more fruitful to consider
religions’ morphologies. He uses a tripartite model
that describes religious communities as (1) diasporic,
(2) transcultural, or (3) global, and in some instances,
religious traditions can represent all three. Christians
from the south of India who are now living in
Houston, Texas, are part of a diasporic community
of Indians, and at the same time, these Christians
can be described as members of a missionary tradition
that now counts its members as representing a full
third of the world’s population.
How to approach the topic
Whether or not it would be prudent to instruct med-
ical trainees on the importance of spiritual concerns in
the lives of their patients and how to interpret these
issues in order to protect the principles of beneficence
and non-maleficence are both large and a very diffi-
cult set of questions. Currently, techniques for asses-
sing spirituality in the clinical setting have ranged
from a single question ‘how are you coping?’ to
more systematic sets of questions that include ‘what
is your religious affiliation?’ and to what might be
described as an elaborate psychosocial model.
Table 1 lists just a few of the many measurement
tools available for the study of religion and spiritual-
ity. A helpful review is available in the Handbook of
Religion and Health(64). These tools are unique in that
they can be applied to patients of many religious
affiliations. Assessing the role spirituality plays in a
patient’s medical decision making and how this may
translate to the protection of the principles of benefi-
cence and non-maleficence is a complicated issue that
invokes problems that can involve the conundrum of
cultural diversity as well as legal concerns over per-
sonal privacy. Is it important for physicians to deter-
mine to what extent a patient’s view of the ‘afterlife’
or his or her beliefs in the power of the miracle inform
their treatment choices or the decisions they make at
the end of life. These are just a few of the issues that
are raised when research physicians begin to
acknowledge the force of religious belief and practice
in the lives of their patients.
In U.S. polls, 40% of people consider it important for
their physicians to address spiritual issues, if they were
seriously ill, and as many as 77% of inpatients want
physicians to address their spiritual needs(47,65). Even
in a study of non-cancer patients, one-third wanted to
 Table 1. Examples of measurement tools
Intrinsic—extrinsic religiosity scale
RCOPE religious coping method
Spiritual perspective scale
Spiritual well being
Functional living index and quality-of-life
Index of core spiritual experiences (INSPIRIT)
FACT functional assessment of chronic illness
therapy scale, faith/assurance subscale and
meaning/purpose subscale
Duke religious index (DUREL)
Intrinsic religiosity
Royal free interview for religious and spiritual
beliefs
Systems of belief inventory (SBI-15)
Fetzer NIA measure of religiousness and
spirituality
Santa Clara strength of religious faith
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
Allport GW. In: The Individual and His Religion:
A Psychological Interpretation. New York: Macmillian, 1950
Pargament KI, Koenig HG, Perez LM. J Clin Psychol
2001;56:519—43
Reed P. Research in Nursing & Health
1987;10:335—44
Paloutzian and Ellison. In: LA Peplau, D. Perlman, eds.
Loneliness: A Sourcebook of Current Theory,
Research, and Therapy, 1982
Kass et al. Journal for the Scientific Study of Religion
1991;30:203—11
Kass et al. Journal for the Scientific Study of Religion
1991;30:203—11
Cella. Oncology 1996;10:(11 Suppl) 233—46
Koenig. (DUREL) Am J Psychiatry
1997;154:885—6
Hoge. Journal for the Scientific Study of Religion
1972;11:369—76
King. Psychological Medicine 1995;25:1125—34
Holland. Psycho Oncology 1998;7:460—9
Fetzer Institute. A report of the Fetzer Institute/National
Institute of Aging Working Group, Kalamazoo, MI, 1999
Sherman AC et al. Psycho-oncology 2001;10:436—43
20 items; religious commitment or
orientation
63 items; religion and coping (also brief
14-item version)
10 items; spirituality and well being in
terminally ill, hospitalized adults
20 items; loneliness, spiritual well being,
and quality of life.
10 items; religious wellbeing. 10 items;
existential well-being
7 items; health outcomes and a new index
of spiritual experience (INSPIRIT)
18—24 items; quality-of-life outcomes:
measurement and validation.
5 items; intrinsic and extrinsic religiousness
and health outcomes
10 items; a validated intrinsic religious
motivation scale
18 items; relates to spiritual and religion
in healthcare
15 items; social support and religious beliefs
31 items; religious history
10 items; the Santa Clara strength of
religious faith questionnaire
Spirituality, religion, and gynecological oncology
191
192 L. M. Ramondetta & D. Sills
be asked about religious beliefs at routine office visits
and two-thirds thought that their physician should be
aware of their religious beliefs(66). Patient’s desire for
physicians to engage in spiritual discussions seems to
increase with the severity of the illness. Given the
constraints of time, some patients, and especially Afri-
can Americans, are more willing to spend a portion of
their office visit discussing what we would term
‘spiritual concerns’, even when it means giving less
time to specifically medical issues(66). At the same
time, Koenig(67) reminds us that a significant minority
of patients (1/3) do not want physicians to discuss
spiritual issues with them. He suggests that the phys-
ician explores first in a general sense what methods
patients use to cope with illness in order to find out
whether spiritual beliefs influence medical decision
making. Some care givers fear that taking a ‘spiritual
history’ represents an endorsement of a patient’s reli-
gious beliefs. Alternatively, physicians do want to
know what is important to their patients. If patients
do not indicate that religious and spiritual issues are
important to them, it is appropriate to move on to
other aspects of medical history assessment(67).
Often, religious practice is associated with behaviors
that affect an individual’s health such as sexual absti-
nence, vegetarianism, and avoidance of alcohol and
smoking. Religious practice might even be associated
with obesity, guilt, and obsessive behavior, and
within these beliefs are varying interpretations that
are important to record. In some patients, a higher
level of spiritual faith correlates with decreased like-
lihood of genetic and screening test participation in
certain populations(68,69). These objective measures
of religious and spiritual beliefs are alone enough to
justify the value of taking a spiritual history. A simple
way to ask about spirituality is a single, open-ended
question ‘Do you have any religious or spiritual
beliefs that you would like me to know about?’ These
questions are still controversial, but some models
have been described. Table 2 lists four samples of
questioning formats for healthcare workers interested
in assessing spiritual well being in their patients.
The problem of what physicians should do with
patient information about spiritual needs and con-
cerns is precisely why many physicians shy away
from initiating discussion of this sort in the first
place. Sloan(70) believes that we should not ask the
questions, because we, as physicians, are not trained
to answer them. Even Olser(71), who fully appreciates
the importance of spirituality in the lives of his
patients, delegated these issues to a chaplain. The
presuppositions, which underlie both Sloan and to
some extent Olser’s responses, assume that the rela-
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
tionship between physician and patient is always
instrumental or finally informational. Both physicians
seem to think that a patient’s spiritual questions are
answerable, on the model of reading a computed
tomography scan or giving a prognosis. Everyone in
cancer work knows that this is not the case. Even
patients know that their physicians are human beings
and that certain kinds of knowledge are beyond even
their expertise. As the historian Roy Porter(72) has so
eloquently pointed out that the healing arts involve
‘listening’ and ‘being present’ to the ill. What patients
want is to be recognized by their physicians as more
than a medical ‘case’ and for their physicians to
understand that they have more than a medical life
to lose. The ill want their physicians to stand with
them against their disease and not to be indifferent to
the outcome.
Better health outcomes research
Is it possible to assess the impact a patient’s spiritual-
ity has on his or her health? Some studies have
defined the influence of religion too narrowly,
arguing simply that certain religious institutions pro-
mote specific healthy lifestyle choices and provide
communal support systems for their members. The
impact religion has on a patient’s health may also
indirectly reflect certain health behaviors, heredity/
epidemiology, psychosocial effects, and beliefs(73).
Others have suggested that spirituality and religious
beliefs improve an individual’s grieving and coping
skills, which can result in a greater sense of mental
and physical well being. Still others have used sur-
vival data, demonstrating that there is a connection
between psychoneuroimmunology and altered
biomarkers(74). This is clearly an evolving field,
and many of these questions and issues remain
unaddressed.
A great deal of research has been devoted to the
problem of correlating improved health outcomes to
prayer, religious attendance, and religious belief(75).
Although a thorough review of this larger question
is beyond the scope of this article, it is important to
note a few key articles. McCullough et al.(76) produced
an excellent meta-analysis of 42 studies on this sub-
ject. He demonstrated that religious involvement is
associated with lower mortality (OR 1.29), and this
relationship is stronger in studies where women
represented the majority of participants. Sephton
et al.(74) evaluated 112 women to establish a relation-
ship between spirituality and immune function. He
found that women with strong spiritual beliefs and
 Table 2. Samples of questioning formats for healthcare workers interested in assessing spiritual well being in their patients
S.P.I.R.I.T.ual history: the SPIRIT is an
acronym for the 6 domains explored
by this tool
H.O.P.E.
Faith, Importance/Influence, Community,
and Address (FICA) Spiritual History
FICA is an acronym for faith,
importance/influence, community, and address address these issues in your care?
LETGO
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
S: spiritual belief system; Maugans TA. The SPIRITual History. Arch Fam Medical 1996;5: 11—16
P: personal spirituality;
I: integration with a spiritual community;
R: ritualized practices and restrictions;
I: implications for medical care;
T: terminal events planning.
H: sources of hope meaning comfort, Anandarajah G, Hight E. Spirituality and medical practice:
strength, peace, love and connection; using the HOPE questions as a practical tool for spiritual assessment.
O: organized religion; American Family Physician 2001; 63: 81—9
P: personal spirituality and practices;
E: effects on medical care and end of life issues.
What is your faith? Puchalski C, Romer AL. Taking a spiritual history allows clinicians
How important is it? to understand patients more fully. J Palliat Medical 2000;3: 129—37
Are you part of a religious community?
How would you like me as your provider to
L: listening to the patients’ story; Bradley. LETGO. J Palliat Care 2000;16: 6—14
E: encouraging the search for meaning (knowing
that you can’t answer the questions);
T: telling of your concern and acknowledging
the pain of loss;
G: generating hope whenever possible;
O: owning your limitations.
Spirituality, religion, and gynecological oncology
193
194 L. M. Ramondetta & D. Sills
extrinsic religiosity scores had increased white blood
cell and total lymphocyte counts. Astin et al. looked at
23 randomized, controlled trials on distant healing.
He was unable to do meta-analysis, but 13/23 studies
reported improved effect of healing in the patients
surveyed(77).
Koenig discusses the effects of religious belief and
activity on the remission of depression in older ill
patients(78). Patients with greater intrinsic religiosity
predicted shorter time to remission of depressive dis-
orders, depressive disorders that were identified at
the time of admission by a validated depression
scale. Reynolds and Powell(79,80) have shown that
attendees of religious services have a 25% decreased
mortality rate in healthy individuals, but no measur-
able effect was seen on the mortality of cancer
patients. This was felt to probably be due to healthy
lifestyle behaviors. Frequency of attendance at reli-
gious services, in other studies, has been shown to
be inversely associated with mortality. What is sur-
prising is that, after controlling all relevant covariates,
this relationship held true only for women!(81)
Although there are consistent reductions in mortality
risk in patients who attend services probably second-
ary to life style changes, there is not consistent evi-
dence to support a dose of religiousness and its effect
on physical health. All the studies are limited by lack
of controls, cross-sectional design, inadequate reli-
gious assessment, small sample size, and lack of
adequate statistical analysis. Attention to religious
variables including forgiveness, altruism, hope, prayer,
and social church involvement in church activities
such as volunteerism, as well as ethnicity, gender,
sex, and standard religious assessment is lacking.
In her 2002 ethnologic study of Moroccan Muslim
village women, Macphee(38) argues that religious
belief is essential to understand the experience of ill-
ness of these women. When medical care is rudimen-
tary, many of these women speak of reducing the
stress and anxiety in their lives and employ the
sounds of prayer to calm and steady them. Quoting
her informants, Macphee writes of the spiritual body
as ‘a life force’ or a ‘mindful presence’ that brings a
sense of unity to these women and enables them to
describe the prayer experience as one that brings
together their ‘mind and their body.’
Interventions
Spiritual intervention trials, such as those that study
church attendance, prayer, healing touch, and other
forms of spiritual activity for the purpose of improv-
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
ing health, are in their infancy. Until now, we have
considered patients who utilize their own religious
beliefs and practices to examine the impact these
beliefs and practices have on patients’ healthcare
experiences. As Gerwood(82) has pointed out, what is
at issue is how meaningful religious beliefs and prac-
tices are to patients. In this context, the issue of inter-
vention, ie, prescribing religious or spiritual practices
to augment health care treatments, sounds and prob-
ably is wrong. Oncologic medicine is invasive
enough. As physicians, we are trying to maximize
patients’ sense of choice and autonomy and not
diminish it. Moreover, there are also theoretical issues
at stake. Some opponents of this sort of research argue
that these studies are in effect trying to ‘prove the
existence of God’ and, more unsettlingly, to use
what James Frazer(83) has termed ‘the magical imagin-
ation’ to prove that humans have the ability to man-
age God’s power to save some individuals and to
forsake others(3).
We think this is an unfair criticism. Research phys-
icians are not hoping to measure the ‘power of God.’
What they are interested in is the impact of patients’
religious beliefs and practices on their healthcare
experience. Scholars of the study of religion would
argue that given the variety of religious beliefs
throughout the world, we cannot hope to establish
the ‘ontological truth’ of one tradition over another.’
What we can do, however, is ‘bracket’ to use Ninian
Smart’s term, the truth claims of various traditions
and move on to consider the ‘human expressions
and experiences associated with religious belief and
practice.’(84) Finally, this is precisely what research
physicians are attempting to do in these studies of
the relationship between health care outcomes and
religious belief and practice.
Other researchers have pushed this issue further,
yet even Halstead’s proposed model does not focus
on transcendent issues. He remains concerned with
the existential issues that confront oncology patients.
He has devised a three-phase process that he outlined
in his 2001 article(85). Phase I would begin the reli-
gious developmental process of coping by helping
patients to decipher life’s meaning, recognizing
human limitations, and helping patients to live with
uncertainty. This early developmental model helps
patients recognize the possibility of death, to help
them deal with their distress and their heightened
sense of vulnerability and, in the face of illness, to
maintain their personal connections with family and
friends. Phase II would involve a more focused con-
frontation with the issue of the human certainty of
death and helping patients come to terms with
 Spirituality, religion, and gynecological oncology
Augustine’s advice to his readers, ‘you are free to
choose, but you are not free to choose your choices.’
Phase III would center upon personal issues relating
to life’s meaning and identifying opportunities for
spiritual growth and renewal in the face of one’s
death.
What we have termed ‘intervention’ may simply
represent the patient’s healthcare team’s attempt to
enable the patient to ‘ease the passage’, to achieve a
‘good and peaceful death’, and to avoid further futile
treatment. Alternatively, it could reflect the phys-
icians willingness to accommodate (1) his or her
patient’s hope for a miracle, (2) his or her refusal to
give up the God of faith, (3) a conviction that every
moment of life is a gift from God, or finally, (4) a
belief that human suffering has redemptive value.
Both Brett and Thorson(86,87) correlated intrinsic reli-
giosity with lower levels of death anxiety.
What is clear to us is that prescribing religion is not
supported in the literature. Yet, despite the complex
nature of spirituality as an epidemiologic construct
(frequently measured as a single item of religious
commitment), statistically significant evidence seems
to support a salutary association between single
representative items of religion and morbidity and
mortality. Moreover, it is important to remember
that this is an emerging field of research. Defining
the terms to be studied is difficult in and of itself.
No study to date has categorically demonstrated that
it is beneficial for patients’ overall healthcare experi-
ence to have their oncologists address these concerns
with them directly.
A number of studies have suggested the complex
and ambivalent impact religious beliefs have had on
oncologic patients. It is important for us to remember
that religious language, in virtually all traditions, con-
siders the possibility of ‘eternal damnation’ or the
‘moral depravity of all God’s creatures’ or the possi-
bility that God has turned his face from humankind.
A patient’s spiritual conflicts can lead to what some
researchers describe as more intensely ‘stressful situ-
ations that theoretically can lead to increased mortal-
ity.’(42,87,88) Quite apart from these research studies,
the history of religious confessional memoir is replete
with the concern believers have about their relation-
ship with God, their fears of eternal punishment, the
prospect of being shunned by one’s religious commu-
nity, or the belief that their illness manifests their own
‘sins.’(88) Even those who do not designate themselves
as particularly religious make the seemingly logical
connection between illness and human character. One
need to simply read Susan Sontag(89) on her own
cancer experience to know that many Americans in
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
195
this century believe that there is a ‘cancer personality’
and that cancer patients have ‘done something’ to
bring the disease upon themselves. Given this climate,
one might ask whether religious belief can contribute
to problems patients have with treatment and screen-
ing compliance?
In his 1999 article, Sloan(90) argues that it is unadvis-
able for research physicians to legitimize this sort of
inquiry. He maintains that all the studies are essen-
tially flawed; they fail to control for age, sex, educa-
tion, socioeconomic status, and health status(90). In
addition, he sites the variability of the definitions for
terms like ‘religion’ or ‘spirituality’, and the difficulty
of determining outcomes or end points. He does
agree, however, that a thorough understanding of a
patient’s religious values can be extremely important
in the discussions surrounding critical medical issues
and the quality of care at the end of a patient’s life.
‘Even in the best studies, the evidence of an associ-
ation between religion, spirituality, and health is weak
and inconsistent. We think it is premature to promote
faith and religion as adjunctive medical treatments.
However, between the extremes of rejecting the idea
that religion and faith can bring comfort to some
people coping with illness and endorsing the view
that physicians should actively promote religious
activity among patients lies a vast uncharted territory
in which guidelines for appropriate behaviors are
needed urgently.’(90)
Recent intervention studies have focused on ‘dis-
tant healing’, particularly the application of prayer.
These prayer studies seem to be organized in terms
of communal or individual practice. Some address
individual guided prayer, others prospective third
party prayer, and in one unique study, retrospective
third party prayer. Many health care professionals
classify prayer as an alternative therapy. Between
1990 and 1997, more and more patients reported that
they used prayer as a form of therapy, noting that the
immediate effects of prayer resulted in a greater sense
of personal calm, less anxiety, and a more positive
outlook(91). These findings are not limited to believing
Christians but can be applied to members of other
Western religious traditions. In one study, Muslim patients
were divided into two groups: one given support
for their religious beliefs in communal Koranic
reading groups and the other with psychotherapeutic
counseling. The group of patients who communally
read the Koran recovered more rapidly than those
who were counseled(92).
In another study, a small group of Christian Asian
American women with breast cancer were asked
open-ended questions regarding the benefits of
196 L. M. Ramondetta & D. Sills
prayer. Their responses suggested that they believed
that their health outcomes were in God’s hands. These
women also stated that they believed in prayer and
that the exercise of prayer gave them strength and
a sense of peace that lessened their fears and their
anxieties(93).
The study of the relationship between prayer and
medicine is not an entirely new topic. The landmark
research that re-ignited the question was designed by
Byrd et al.(94) and published in 1988. Dr Byrd, a Chris-
tian cardiologist, assigned ‘Born-again’ Christians to
prayer for half of 393 cardiac care unit (CCU) patients.
The three outcomes prayed for included (1) rapid
recovery, (2) prevention of death, and (3) prevention
of complications. He also measured, however, 23
other outcomes, and although 14/23 favored the
prayed for group, none were statistically significant.
There was not a significant difference in the number
of days in the CCU and no significant differences in
the number of deaths(94). In 1999, Harris studied CCU
patients without their knowledge in an IRB-approved
protocol(95). Distant Christian intercessors were
employed using a ‘global score’ designed for the
study. There were 10% fewer complications in the
group prayed for than in those for whom no prayers
were offered. At the same time, when researchers
used individual measures, they found no significant
differences between the groups(95). In 2001, Mathews
et al. designed a study that contrasted the effects of
distant prayer, positive visualization, and life expect-
ancy on the well being of dialysis patients. In this
trial, there were no differences between any of the
groups(96). This trial exercised no negative controls.
Patients either received or thought they received one
of the two interventions. Although the placebo effect
may be valid in drug studies, it remains to be seen
whether this is a reasonable control in studies
designed to establish the relationship between
human belief and human health.
Clearly, there are numerous difficulties with prayer
studies. Among the many issues are defining end-
points (eg, death versus cure versus better QOL),
measuring a dose and frequency of prayer, addressing
the issues of informed consent, and identifying
prayer-void control groups. Finally, there remains
what we see as the unanswerable question as to
whether directed prayer is answered by what theolo-
gians have long-described as the ‘holy other.’(16) No
research physician or research scientist for that matter
has proposed a reliable model that could possibly
measure this outcome. We may be on firmer ground,
if we follow the lead of two research physicians,
Andrew Newberg, M.D., and Eugene D’Aquili,
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
M.D., Ph.D., who have investigated what they call
‘brain science and the biology of belief.’(97) These
research physicians are not hoping to measure
‘God’s work in the world.’ What is interesting for
Drs Newberg and D’Aquili is the science that seems
to support their contention that human beings are
hard-wired to be religious. As they understand
human biology, the very structure of the human
brain enables us to transcend our own experience in
search of something universal, something beyond the
particulars of our own experience, and to seek a
greater meaning to our individual lives. In their con-
struction of the relationship between the religious
experience and human biology, the religious impulse
is rooted in the biology of the brain itself(97). What
they are attempting to measure is human energy, not
metaphysical energy. Cancer researchers who are
investigating the relationship between a patient’s reli-
giosity and his or her health are by definition dealing
with patients in extremis and may be attempting
to measure the same sort of human response which
Drs Newberg and D’Aquill are after. The human
journey is finite, and as all oncologic clinicians
know, the cancer experience involves the patient’s
whole self, medical, emotional, and spiritual.
Physician satisfaction
‘Every time I look into the eyes of a person who’s ill or
dying, I see my own life and death.’(98) What Gordon
is addressing here is the often underappreciated
benefit physicians can sometimes derive when they
engage their patients in conversations that address
issues we have characterized in this review article as
falling under the categories of ‘the religious and the
spiritual.’ Gordon’s observation expresses his own
deeply felt sense of human solidarity with his patients
who are ill and in extremis. Block makes a similar
point in his 2001 study in which he notes the degree
to which healthcare professionals understand their
sense of personal satisfaction and the sense of privi-
lege they feel in helping their patients voice their own
existential concerns to someone who is sympathetic,
present, and who has, in Blocks’ terms, ‘an under-
standing ear.’(99)
Physicians know that while the disease structures
the relationship between patients and their caregivers,
it is often a patient’s desire to ‘improve in the nick of
time’, to quote Thoreau(100), that can provide the
energy for the elaboration of that relationship into
something that can be both intimate and celebratory
 Spirituality, religion, and gynecological oncology
for both patient and physician. Physicians don’t
generally initiate conversations about spiritual ques-
tions. They may be the ones to say, ‘there is nothing
more we can do’, but ordinarily, they leave issues
related to what we now euphemistically call ‘spirit-
uality’ to the cancer patient. These really are ques-
tions of communication.
Most physicians would be able to describe a ‘good
death.’ In most cases, it involves at the very least an
intimate conversation between patient and physician
that can afford both a greater appreciation of the gifts
of being alive and a renewable sense of hopefulness
about human resiliency. Even patients know that
death comes to us all and that the dying itself does
not necessarily mean that cancer has won.
For many of us in health care, the work itself is both
an occupation and a vocation. While addressing
patient’s spirituality can be challenging, the attempt
to communicate at a deeper level can enhance the
caregiver—patient relationship(101). We know that, for
many patients, their religious worldview, their beliefs,
and practices enable them to deal more effectively
with their disease. We also know that both patients
and physicians bring their own experiences, their
beliefs, their values, and worldviews to bear in the
clinical setting. While having ‘an understanding ear’
may prove beneficial for patients, providing patients
with a greater sense of individual autonomy and
integrity, listening to patients express their religious
beliefs and their fear of mortality, may invoke for
heathcare professionals a reaction that Gordon
knows all too well(102). By invoking a sense of solidar-
ity with the ill, what Arthur Frank describes as an
enhanced sense of empathy, healthcare professionals
may find themselves grappling with these same
issues in their own lives(103). In this context, it may
prove interesting to examine the work of actor Megan
Cole, who is currently offering courses at the University
of Texas Medical Center on ‘The Skills of Empathy.’
For Cole, the art and technique of acting can
provide physicians and caregivers with the tools
necessary to be both present for their patients and,
at the same time, not to be overwhelmed by the
human drama of solidarity that is part of the finitude
of all life.
In his widely reviewed The Art of Happiness the
Dalai Lama suggests that the healing insights of Bud-
dhism are also reflected in the other major world
religions as well as the secular fields of contemporary
health care(104). All these disciplines recognize that life
hurts and that people suffer, physically, mentally, and
spiritually. His Holiness is not interested in convert-
ing the unconverted to Tibetian Buddhism. It is rather
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
197
the case that he recognizes that his status as a global
religious leader puts him in a unique position, one
that enables him to reflect publicly on the transcul-
tural character of human existence. While he uses
specifically Buddhist terms, like ‘compassion’, ‘mind-
fulness’, or ‘being attentive’, what he is after is some-
thing larger, something that recognizes what he
understand to be the possibility of ‘really real’ com-
munication between people, to use Geertz’(23) term.
As Geertz imagines the world for the religiously
inclined, it is divided between the everyday, the regu-
lar, the apparent world of the real, and the ‘really
real’, the realm where Christians would say ‘the
meek will inherit the earth’ and the Jews would say
‘we will all live in the World to Come, whatever that
means.’ This is the place where ‘miracles happen’
according to Marianne Williamson or as one bone
marrow transplant patient put it, ‘where the stuff
that makes the grass green and gets me out of bed,
is essentially the same stuff, and it is not personal.’(105)
A cancer diagnosis inclines patients to reflect on the
existential issues that more often than not are shelved
in the routines of daily life. Physicians who treat
cancer by definition inhabit a medical and the meta-
physical world of their patients. and it is often the
case that their patients need to talk about both aspects
of their illness, its physical form as well as its spiritual
aspects.
How physicians manage these conversations is the
subtext for many of these research studies we have
reviewed. Yet, the difficulty remains, is it possible to
measure patient’s religiosity; is it advisable to do so?
Alternatively, do physicians need training in talking
about ‘the really real?’ What is clear from the material
we have reviewed is that this emerging field is wrest-
ling with border problems, problem of definition.
While the White House’s definition of religion may
be sufficiently broad to include the spiritual diversity
of America at the beginning of the 21st century, it is
not sufficiently nuanced to manage neither the impact
of globalization on what 20 years ago were called ‘the
world’s religions’ nor to accommodate the perspec-
tives of the ‘really ill’ who are not religiously inclined
but do seek comfort and solace as they face what
Henry James called the last ‘great thing.’(106) Both
patients and physicians alike recognize the centrality
of communication in the cancer journey. To be able to
speak with frank honesty and to develop a degree of
intimacy with one’s physicians enables the patient to
take advantage of ‘the nick of time.’ It also enables
them to face treatment and illness with a sense that
ones’ caregivers stand with them and are not indiffer-
ent to the outcome.
198 L. M. Ramondetta & D. Sills
As Giardin points out ‘whether the spiritual should
be tested by the rigors of the scientific community will
remain open to lively discussion for some time. . .
what is significant for healthcare providers is that. . .
(many of) their patients believe in spiritual interven-
tions and practice them.’(107) It seems clear to us that
this dimension should be part of the overall assess-
ment that health care providers make in their evalu-
ation of patients.
Finally, what makes the experience real for the
patient is good communication with his or her phys-
ician, and what can make our work ‘real’ for us and
often serves as a motivation for us is the experience of
participating in a relationship that invariably invokes
human questions about the value of suffering as well
as meaning and purpose of life itself. Spirituality then
is a dimension that should be assessed by the health-
care provider(107).
Conclusion
Students of religion and scientists both know that the
paradigms within which they work can sometimes
overlap, but rarely if ever fully converge. Religion
cannot answer ‘how’ questions and science cannot
answer ‘why’ questions(108). What religionists and
scientist—physicians share and what they share with
all human beings is the knowledge that all of us ‘will
surely die.’ The role of the physician is not to solve the
spiritual problems of his or her patient. It is rather the
case that physicians learn to support an environment
where human spirituality can flourish and, when pos-
sible, where healing can take place(109).
In his 2001 study, Taylor(110) argues ‘to be able to
recognize another’s spiritual and cultural values and
beliefs, nurses must possess some self-awareness of
their own spiritual values.’ They must be able to ask
themselves what beliefs do I have about where I came
from, about where am I going? What is the purpose of
my life? How do my beliefs show themselves in my
every day life? What do I think causes disease? What
does it mean to me when bad things happen to good
people? What is most meaningful to me? What is the
character of my own worldview? Are there customs or
ritual practices I observe that reinforce my values? How
difficult is it for me to understand patients whose
customs and worldview are distinct from my own?
All religious traditions, except perhaps Christian
Science, know that life hurts. Most traditions also
agree that human beings are at least in one respect
finite and more often than not ignorant and corrupt.
Anthropologist Clifford Geertz has put it this way,
# 2004 IGCS, International Journal of Gynecological Cancer 14, 183—201
‘religions don’t solve the problem of suffering, they
make suffering sufferable.’ In the context of oncologic
work, it may not be unfair to stretch this analogy to
apply it to clinical physicians(23). They too make the
suffering of the cancer experience sufferable. What
this new interest in the connection between the heal-
ing of the body and the healing of the spirit suggests
for oncologic research physicians is a recognition of
the comprehensive character of cancer treatment and
the understanding that both physicians and patients
share a knowledge that what patients lose in their
battle with cancer is more than simply a medical life.
Concerns for the spiritual health of patients may
prove significant both for a patient’s comprehensive
sense of well-being and for the relationship that is
created between patients and physicians and patients
and caregivers, as they together face what both agree
is often a relentless and at times invincible enemy.
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Accepted for publication January 13, 2004