By Ramy Sedhom, MD

Is cancer care a spiritual practice? Although this question is the inspiration for this piece, it may seem odd to most oncologists practicing in the western world today. Most would agree health care is an intricate form of applied science. There are some parts of our practice that are not science, which we typically call the “art” of medicine. As the era of genomics is dawning, we are slowly losing the spiritual nature of our work. As we look closer at ourselves and hope to uncover the rare mutation and match targeted therapy, we lose sight of our collective being. We struggle to acknowledge the disease-agnostic crisis of what it means to live with cancer while seeking precision therapy.

Many people equate spirituality with religion. Although conceptually related, they are not synonyms. Spirituality is much broader than religion. Spirituality is defined by the characteristics and qualities of one’s relationship with the transcendent. It includes attitudes, habits, and practices. Some call the transcendent “God.” For others, spirituality is a calling to make the world a better place, and for these individuals the transcendent represents a connection to a larger human community. This may be focused on what is natural, as opposed to what is supernatural, with secular humanism as an example. By contrast, religion is a specific set of beliefs about the transcendent, held in common by a community of persons. For me, that religion is Orthodox Christianity. It involves a particular language (Coptic) used to describe spiritual experiences and a communal sharing of key beliefs. It also involves a set of practices, texts, rituals, teachings, funny hats, and particularly long services.

As a fellow caring for a diverse population of patients in Baltimore, I witnessed spirituality and religion in many different forms and colors.   

I was drawn to oncology because of the relationships the doctors maintained with their patients. Yet, throughout my training, I was never asked to consider the spiritual needs of my patients with cancer. As a former religious studies major, I found this odd. Many of our patients consider spirituality or religion an important part of their life.¹ Spirituality and religion are personal—and as Jewish philosopher and theologian Abraham Heschel once said in his address to an audience of physicians, “To heal a person, one must first be a person.”²  I think as oncologists, and as persons, we should ask our patients whether spirituality, or religion, is an important part of their lives.

As our palliative care colleagues continue to remind us, to heal, one must make whole. One cannot simply pursue treating the tumor, one must treat the person. As oncologists, if we are committed to healing patients, we must understand not only what cancer does to patients’ bodies, but what the disease does to them in spirit. By spirit, I refer to how they grapple with existential questions. By doing so, we will rediscover that the oncology clinic is truly a spiritual place.

Ms. Chow* was a patient of mine with gastric cancer. She was always accompanied by her daughter and our Mandarin language interpreter. I had difficulty establishing a warm relationship with her throughout her six cycles of adjuvant chemotherapy, but it was not for lack of trying. She was a women of few words. She communicated more with her beautiful smile. But on a winter day, during her first surveillance visit after completing therapy, she closed our conversation with a statement that left me taken aback. The interpreter, similarly surprised, shared her words: “Merry Christmas.  Always remember. My Jesus. Best medicine.”

As I later came to know, Ms. Chow was both very religious and spiritual. To her, cancer was a spiritual event. And though I had diligently assessed her blood counts, screened for neuropathy, and made sure she was able to afford her medicines, I failed to consider how cancer had disturbed her soul. In future visits, she had shared many of the transcendent questions brought about by her illness—questions about meaning, value, and relationship. Her cancer diagnosis forced her to reconsider a fractured relationship with her daughter. In fact, she had moved to America to reconnect with her daughter, with whom she had not spoken for over 10 years.

I later found that many patients ask these questions. Ms. Chow’s story is not unique. More importantly, I’ve realized that by prompting a discussion about spirituality myself, I invite my patients to grapple with these questions. Spirituality should be considered as a potentially important component of every patient’s life. Clinical tools, such as FICA, were developed to help health care professionals address spiritual issues with patients. It was validated in cancer clinics. It is also used to help identify spiritual issues patients face, spiritual distress, and patients’ spiritual resources of strength.³  

As modern clinical practice has it, we know so little about the ways in which we touch the lives of our patients—or the ways we fail them. I attended a “Day of Remembrance” hosted at Johns Hopkins. The event is organized to remember the families of the patients we lost in the previous calendar year. One caregiver told a beautiful story of the relationship she had with her husband’s oncologist, Dr. Ross C. Donehower. She shared that near the end of her husband’s struggle with colon cancer, Dr. Donehower recommended holding therapy. It was not the first delay, but she was surprised by the rationale: “It’s time to go on that cruise you’ve both been talking about for the past year or two,” he advised.

“Wow,” I thought. Good medicine. I saw this myself in Dr. Donehower’s clinic—he attends to the spiritual and personal needs of his patients.

From my perspective, as oncologists, our healing presence can be found in the fissures of daily practice. Too few of us bother to reflect on it or talk to each other about it. Spirituality often is found in conversations with our patients who are dying, in countless moments in the office, and in the hospital where we communicate meaning and value to our patients daily. Immunotherapy and CAR T-cells do not have to get in the way of understanding the clinical encounter as a spiritual practice, although they can. If we think of ourselves only as a mechanism of drug delivery, we violate the trust patients place in us.

It is important to communicate this to patients and their loved ones, to avoid the falsehood that their story begins and ends with cancer. The availability of new, effective drugs to manage cancer may have changed clinical practice and cancer clinical trials, but there will never be transcendent pharmacology. Spirituality in cancer care begins when we are aware that existential questions arise in and through illness, and that meaning and suffering can be addressed by us, the providers of care.

I will close by sharing some details from my last day rounding on the solid tumor service. I imagine my experience is likely similar to many of yours.

On morning rounds, I saw an 80-year-old veteran with altered mental status, lung cancer, and no housing. His room was next to a 47-year-old alcoholic grandmother who could not afford her medicines. She looked 87. I also cared for a 28-year-old woman dying of ovarian cancer. She had two young children, both under the age of 5. Her husband did his best to be at her side, but struggled to take time off of work.  Meanwhile, in clinic, my patient with breast cancer was filing for divorce. Her husband had cheated on her after her mastectomy. I also taught medical students and residents, some of whom were jaded from the moment they entered the workplace. I saw them all. And I’m sure you did too.

Are our eyes open or are they prevented from seeing the suffering?

Working in our oncology clinics, where patient visits are reduced to minutes, it becomes unimaginable that questions of meaning can be addressed. Yet these neglected questions of meaning constitute the spiritual practice of health care. As an optimist, I still believe that no amount of economic transformation can alter the meaning and value of health care. I know that nothing can ever eradicate the interpersonal nature of our healing relationship.

So tomorrow, I will continue to work with my patients who ask why they must suffer, and question their value when they are no longer “productive.” I will ask if they consider themselves spiritual or religious, what helps them cope with stress, and ultimately, what gives their life meaning. In fact, considering a patient’s spirituality is an essential component of whole-person care. Spiritual assessments can be as important as physical, emotional, or financial toxicity. But, we will never know what that means for individual patients if we don’t ask.

Spirituality in the clinic. This is strong medicine.

*Patient name and identifying details changed for privacy.

Dr. Sedhom is a medical oncology fellow at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins. He will begin a palliative medicine fellowship at Memorial Sloan Kettering following the completion of his oncology training. Follow him on Twitter @ramsedhom.

References

1. Gillum RF. Frequency of attendance at religious services and leisure-time physical activity in American women and men: the Third National Health and Nutrition Examination Survey. Ann Behav Med. 2006;31:30-5.
2. Heschel A. The Insecurity of Freedom. New York: Noonday Press, Strauss, Firoux, 1966, 24-38.
3. Borneman T, Ferrell B, Puchalski CM. Evaluation of the FICA Tool for Spiritual Assessment. J Pain Symptom Manage. 2010;40:163-73.