Traditional and Complementary Medicine Among Indigenous Cancer Patients

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Breast cancer is one of the major healthcare issues, which affects women all around the globe. The current advances in the treatment and screening indicate the presence of a prominent and profound improvement within these processes. It is evident that traditional approaches play a central role in ensuring that breast cancer does not lead to fatal outcomes by increasing survival rates. However, it is critically important not to overlook the undeniable relevance of complementary alternative medicine (CAM) and its role during a patient’s struggles with the given health problem. One should not ignore that CAM practice revolves around various religious and cultural practices, which are deeply ingrained within the diagnosis, treatment, and post-survival phases. Although a wide range of cultures utilizes CAM in a different fashion, the monotheistic Abrahamic religions primarily adhere to prayer and faith (Ahmadi et al., 2018). The corresponding structure of the given chapter will primarily focus on outlining the purpose and significance of the study as well as its problem statement with the emphasis on the background of the issue.

Therefore, it is necessary to increase the overall understanding of the role of CAM among breast cancer patients alongside identifying the key motivating factors, where the prime manifestations of the phenomenon are faith and prayer. Thus, the research questions are:

1. How do stages of breast cancer diagnosis influence the choice of faith and prayer as the sole explicit forms of complimentary alternative medicine (CAM)?
2. What draws a breast cancer patient to faith and prayer as explicit forms of CAM? and
3. How do faith and prayer, as CAM forms, affect physical, mental, emotional, and social health?

Background

The high incidence of cancer is a global risk of modern times. The impact of powerful stress factors of the disease and often extremely difficult treatment leads to a decrease in the performance and quality of life of patients with oncological diagnoses. At the same time, it is generally accepted that the result of treatment largely depends on the patient’s position in life and on the choice of a strategy for overcoming a stressful situation. Today, in combination with other methods of treating oncological diseases, radiation therapy is often used, which requires mandatory preparation, several sessions, immobilization of the patient during a session, and the possibility of radiation complications.

Breast cancer occurs when breast cells, due to mutations, begin to divide uncontrollably and spread to surrounding tissues. These cells form a tumor, which can be detected by palpation of the breast or mammography. Cancer can form in different parts of the breast. Most breast tumors develop from the epithelium of the ducts that carry milk to the nipple, or ductal cancer, but others develop from glandular cells, such as lobular cancer. There are also less common forms, including non-specific cancers, sarcomas, and breast lymphoma.

The tumor can grow locally, spread through the lymphatic system to the lymph nodes (regional metastasis), and also spread throughout the body (distant metastasis). Regional lymph nodes include axillary, intrathoracic, supra- and subclavian lymph nodes – on the same side as the tumor in the mammary gland. The stage, prognosis, and extent of breast cancer treatment depend on the size of the tumor, the involvement of regional lymph nodes, and the absence or presence of distant metastases.

Signs and symptoms of breast cancer referred to the presence of a solid tumor in the breast, which does not decrease at different phases of the menstrual cycle but increases over time. In addition, the symptom may be nipple retraction, nipple discharge, breast or nipple pain, and skin infiltration in the breast area. Skin ulceration in the breast area, swelling of all or part of the breast, unexplained weight loss, weakness, and redness, peeling or thickening of the nipple or breast skin may also occur.

Historical Context

Historically, breast cancer was always a major health issue, which is one of the most aggressive and dangerous types of oncological disturbances among the female population. Although the main topic is focused on breast cancer and cancers in general, they are primarily handled and treated through traditional medicine or TM. Despite its high degree of usefulness and effectiveness, some case of the disease also requires powerful coping mechanism due to the uncertainty of the outcomes.

Therefore, it is evident why there are a strong prevalence and presence of complementary alternative medicine or CAM, which can be useful in conjunction with the main one. If the topic is viewed within its historical context, it becomes clear that religion and cultural practices play a central role in determining the form of CAM exhibited by a particular group of people. For instance, a study from Malaysia showcases how Islamic belief plays a vital place within the coping mechanisms among local cancer patients (Ahmadi et al., 2018). Islam, being one of the dominant monotheistic Abrahamic religions of the world, can be a representative element of other religions, such as Christianity and Judaism. These coping mechanisms are primarily centered around faith and prayer, which differ in the style of performance but possess the same function of connecting with God.

Social Context

Social context plays a vital role in the prevalence of CAM use among cancer patients, including breast cancer. One should be aware that not all cases among oncology-suffering patients can result in the desired outcome, where a person has a chance for survival. In some instances, the treatment might not be useful since the identified stage is the late one. In other words, it is critical for such people to rely on coping mechanisms, which can be derived through a wide range of measures. In addition, coping with the given challenge is still relevant among patients, which have a chance for survival. The mere process of undergoing the treatment can be stressful and depressing for many individuals, which is why complimentary alternative medicine is prevalent. For instance, another evidence from Indigenous Australians demonstrates that the significance of CAM is as important as traditional medicine (Adams et al., 2015). Therefore, it proves that usage of CAM is not limited to religious practices because various cultures, which developed independently, also possess alternative approaches in regards to cancer.

Although the main subject is centered around the role of prayer and faith, CAM can be manifested in a number of forms. For example, it is stated that Caribbean communities also adhere to complementary alternative medicine in the form of spiritual therapies and medicinal herbs, where health care providers might not be fully aware of these actions (Bahall, 2017). In other words, herbs alongside certain rituals can be a part of complimentary alternative medicine, which can go in conjunction or even interfere with the traditional measures. Thus, in regards to social context, CAM is of paramount importance because it is present in all cultural and religious elements, and it serves the purpose of building a strong and effective coping mechanism.

Theoretical Context

It is important to state that there is a solid theoretical context, which is based on the various advantages and disadvantages of CAM-based practices in regards to breast cancer and cancer in general. Therefore, such trends raise both concerns and interest regarding the effectiveness and other ramification of these approaches, where more detailed studies are required (Buckner et al., 2018). In other words, it is evident that some practices, such as herbs, might counteract or even suppress the effect of traditional cancer treatment procedures. For example, a person undergoing chemotherapy is generally put in a weakened state, where the use of toxic or harmful herbs might result in undesired complications.

However, the topic is primarily focused on faith and prayer, which are not harmful on their own. One should be aware that the use of religion and its specific elements can be useful for improving the overall situation in regards to cancer. For example, faith-based health promotion programs can be highly useful in the educational process among people of color and minorities (Brown & Cowart, 2018). Therefore, there is a certain appeal and authority, which emanates from such approaches, and it is evidently helpful to illuminate key causes and risk factors of breast cancer. There are no in-depth studies on the importance of religion among onco-patients, which makes the analysis of CAM even more relevant.

The proposed research will provide an invaluable evidence and data on the role of faith and prayer among breast cancer patients. The benefit will encompass a wide range of cultures, which practice Abrahamic religions and primarily communicate with God through the specified means. Although the existing studies mainly reveal that CAM is prevalent among all cultures and can be useful in conjunction with certain approaches, such as education, there is not solid data on the direct impact of most common practices, which are prayer and faith. Thus, the proposed study will deepen the contemporary knowledge on the given subject and set directions for further researches.

Situation to Self

The proposed research is based on my motivation to establish knowledge of the role of faith and prayer among breast cancer patients. Although seeking the truth is a noble goal, cancer, and its treatment is a complex and complicated issue, which is why my main focus will be put on the epistemological and ontological assumptions. I will attempt to learn about the effects of these practices as key elements of CAM as well as reveal the intricacies of its implementation in the daily lives of breast cancer patients. Therefore, it is evident that the paradigm in regards to such an approach will be manifested in pragmatism, where CAM practices will not be viewed as a sole cancer treatment procedure but rather as complimentary and practical measures for improving coping mechanisms. In addition, it is important to note that the proposed study will utilize two key frameworks, which are the CAM decision-making process and the CAM modality integrated decision-making model. Both the former and latter are built on the basis of the decision tree model, which describes alternative healthcare options among patients with oncological complications (Chowdhuri & Kundu, 2020). They will provide invaluable insight into how cancer patients proceed with adhering or dismissing faith and prayer as CAM methods.

Problem Statement

The problem statement of the proposed research is rooted in the fact that many breast cancer patients and cancer patients in general use or adhere to complimentary alternative medicine. The evidence is clear that such a phenomenon is persistent across a wide range of cultures and practices among the most dominant religions. The current literature reveals the commonality of the presence of these practices, where cancer patients compliment their traditional treatments with various rituals, prayers, and even herbs (Bahall, 2017). In other words, the notion is not a unique or isolated incident, but rather a highly prevalent occurrence. Therefore, the problem lies in the fact that there is little to no understanding of the driver and catalyzers of such behavior. It is also not clear whether or not there is a strict relationship between various stages of cancer and one’s willingness to adhere to prayer and faith as the sole explicit forms of CAM. In addition, the problem is also manifested in the lack of sufficient knowledge on the effects of faith and prayer on a person’s physical, mental, emotional, and social health.

Purpose Statement

The purpose of this phenomenological study is to understand the role of faith and prayer, as forms of complimentary alternative medicine, for breast cancer patients at various stages of the disease’s progression, as well as to identify key driving factors behind the overall adherence to the practice. Alongside the main purpose, the proposed research will make an attempt to illuminate the overall effect of faith and prayer on an individual’s physical, mental, emotional, and social health. The theory guiding this study is based on two key frameworks, which are the CAM decision-making process and CAM modality integrated decision-making model, as they explain the general decision-making elements of a patient under severe stress, such as cancer (Chowdhuri & Kundu, 2020). Therefore, the proposed research is based on the provisions of the regulatory approach to the analysis of stress, the conceptual paradigm of individual diagnosis and correction of stress, and a proactive approach to the study of coping behavior.

In addition, it is important to improve the understanding of the model of the functional system of conscious regulation of activity and the idea of the role of effective psychological self-regulation of the state in stressful conditions in the formation of a person’s adaptive potential. Therefore, in this context, it is proposed to conduct a study, the purpose of which was to analyze the proactive resources for overcoming chronic stress in patients with oncological diagnoses of breast cancer undergoing therapy.

Significance of the Study

The significance of the study can be described as a contribution to the current understanding of the importance of complimentary alternative medicine among cancer patients. Although there is a number of research data on the prevalence of CAM, there is little to no succinct knowledge on the impact of prayer and faith among specific cancer types, such as breast cancer. In addition, the study will reveal the key driving factors behind a patient’s choice to adhere to CAM in conjunction with the traditional treatment procedures. The research will illuminate the overall impact of complimentary alternative medicine on a person’s social, emotional, mental, and physical health. One might also argue that faith and prayer are one of the most common CAM practices due to the sheer prevalence of followers of Abrahamic religions, such as Christianity, Islam, and Judaism. All these major world religions put prayer and faith as central pillars of the religious practice, and thus, it is useful to deepen the current understanding of CAM within the context of faith and prayer.

There is also a practical use for the results of the proposed research because they guide physicians, oncologists, and nurses in their overall understanding of the role of complimentary alternative medicine in the cancer treatment process. For example, faith-based educational programs showed a high level of success in regards to promoting cancer awareness and the key mechanisms behind preventing and proceeding with the treatments (Brown & Cowart, 2018). Therefore, one might argue that CAM might lead to an improved experience throughout the breast cancer treatment procedures due to the overall effect in the emotional aspect. In addition, the study is significant because it might illuminate the critical pitfalls of using complimentary alternative medicine in conjunction with traditional treatment practices (Buckner et al., 2018). Breast cancer is among the most aggressive and widespread types of oncological issues, which is why the proposed research will have value in improving the existing form of care delivered to patients. The main effect might be manifested in enhancing breast cancer treatment procedures by integrating various CAM options or even programs, where patients are allowed to access the faith-based or prayer-based services.

Moreover, the study will reveal the relationship between particular breast cancer stages and CAM usage as well as illuminate the main driving factor behind the overall adherence. This will allow medical experts to derive invaluable data in regards to the patients’ decision-making process under such stress. By understanding the general role of the most common CAM practices, which are faith and prayer, it will be possible to design better cancer treatment programs, where the process is not merely focused on one’s physical state. The research will enable the implementation of improvements in regards to a cancer patient’s emotional, social, and mental health, which are also critical in the healing and recovery process. It is also more ethical to ensure that the potentially last days of a person’s life are spent in a state of happiness and satisfaction rather than fear and dread. In other words, regardless of whether there are direct improvements of CAM practices on the overall breast cancer survival rates, it is moral and ethical to implement changes, which lead to an enhanced emotional and mental well-being.

Research Questions

1. How do stages of breast cancer diagnosis influence the choice of faith and prayer as the sole explicit forms of complimentary alternative medicine (CAM)?
2. What draws a breast cancer patient to faith and prayer as explicit forms of CAM?
3. How do faith and prayer, as CAM forms, affect physical, mental, emotional, and social health?

The first research question will focus on how the severity of stress from cancer can affect the adherence rate towards CAM in the form of prayer and faith. It is revealed that faith-based education can be effective in bringing awareness (Brown & Cowart, 2018). However, there is no specific study on breast cancer stages and their relationship with CAM. In addition, it is important to note that there are a number of manifestations of CAM, but one might argue that faith and prayer are the most explicit forms. This why it is critical to understand the key driving factors behind the use of complimentary alternative medicine among cancer patients. The last research question seeks to illuminate the general effect of faith and prayer on one’s physical, mental, emotional, and social health. If there is an indication of improvement, it will be useful for enhancing the traditional treatment process.

Definitions

1. Cancer – a set of diseases, which caused by an uncontrolled and abnormal cell division with their subsequent spread (American Cancer Society (ACS), 2019a).
2. Mammography – a low dose X-ray procedure, which is needed to detect the presence of breast cancer, and it is useful at identifying the disease during the early stages. (American Cancer Society (ACS), 2019a).
3. CAM – complimentary alternative medicine is set of cultural and religious practices, which are excluded from the traditional cancer treatment approaches (Bahall, 2017).
4. Metastasis – is a part of the primary tumor, which spread to another site within the body (American Cancer Society (ACS), 2019b).

Summary

The proposed study’s key problem statement is based on the fact that CAM is prevalent across cultures and religions, and it takes a wide range of forms. However, there is little to no understanding behind the essential driving factors, which make a cancer patient adhere to these practices. Therefore, the research will deepen the current knowledge on the issue by revealing the relationship between a breast cancer-based stress or cancer stage and motivation to integrate CAM. It will also identify the overall impact of faith and prayer on one’s health elements.

Literature Review

Breast cancer is the most often diagnosed life threatening cancer in women and the leading cause of cancer death among women (ACS, 2019a; BCRF, 2020), though survival rates for breast cancer have improved significantly, particularly in younger women (Brenner et al., 2016; Sharma et al., 2010) and even though survival times have improved significantly (BCRF, 2020; Howley, 2019). Patients diagnosed with breast cancer turn to traditional medicine to target the cancer and treat the physical body (Adams et al., 2015; Bellavance & Kesmodel, 2016; Gall et al., 2018; Tolson, 2019). But many women diagnosed with breast cancer also rely on one or more forms of complimentary alternative medicine (CAM) to tend to their physical, cognitive (mental), affective (emotional), social, and/or spiritual health, healing, and well-being. Among these forms of CAM are religiousness and spirituality and the use of faith and prayer. Indeed, research by Neuhouser et al. (2016) shows that following diagnosis, approximately 50 to 75 percent of all breast cancer patients use at least one form of CAM. Yet despite these numbers, forms of CAM are understudied and little is known about their interactions with traditional cancer treatments or their correlative outcomes (Buckner et al., 2018; Neuhouser et al., 2016; Porter et al., 2019; Tolson, 2019). The purpose of this study is therefore to further explore whether faith and prayer, as forms of CAM added to standard medical treatment(s), can help heal and even cure women with breast cancer.

The research questions used to guide this study include the following:

1. How do stages of breast cancer diagnosis influence the choice of faith and prayer as the sole explicit forms of complimentary alternative medicine (CAM)?
2. What draws a breast cancer patient to faith and prayer as explicit forms of CAM? and
3. How do faith and prayer, as forms of CAM, affect physical, mental, emotional, and social health?

To answer these questions, a review of the literature will be accompanied by a phenomenological research design. The study methodology will include semi-structured, one-on-one interviews with breast cancer survivors, for insight into their experiences, including each woman’s overall diagnosis, choices of treatment, faith-based approached to healing, years surviving breast cancer, and the quality of life after breast cancer. The results of this study may add to the literature in support of faith-based care for women diagnosed with breast cancer, thereby helping to close the gap in the research.

Breast Cancer Overview

There are several types or common forms of breast cancer, including non-invasive ductal carcinoma in situ, (at the original site), invasive ductal carcinoma, inflammatory breast cancer, and metastatic breast cancer (Akram et al., 2017; Feng, et al., 2018; NBCF, 2019; Siegel et al., 2019). These types are commonly grouped into one of three categories: non-invasive, invasive, or metastatic (Feng et al., 2018).

Stages of Breast Cancer

While Kuhl (2015) maintains that breast cancer is not a single disease and that tumor biology beats staging or classification of breast cancer, treatment has typically been based on TNM classification system maintained by the American Joint Committee on Cancer (AJCC) and the International Union for Cancer Control (UICC)—given T: the size of the tumor, N: the presence or absence of lymph node metastases, and M: the presence or absence of distant metastases (spread) (ACS, 2020a; Kuhl, 2015). The stages are numbered and lettered 0, I, II, III, and IV (ACS, 2020a; Akram et al., 2017):

Stage 0: Stage O cancer is carcinoma in situ. The cancer is at a very early stage, with abnormal cells lining the breast duct(s), existing only in the area where it first developed, and not spread to other tissue nearby (ACS, 2020a; Akram et al., 2017).

Stage I: Stage I breast cancer is also identified as early-stage breast cancer (Hawley et al., 2017), which is the second-least-advanced cancer with a better outlook than it is for the later stages: the tumors are less than two centimeters (3/4 of an inch) across and still have not spread to lymph nodes (ACS, 2020a; Akram et al., 2017).

Stage II: Stage II tumors are larger, between two and five centimeters across, and typically have spread to the nearby (underarm) lymph nodes but not to other parts of the body (ACS, 2020a; Akram 2017; Lewis Jr., 2017).

Stage III: Stage III tumors are the larger Stage II tumors, but they have spread to underarm lymph nodes, have grown more deeply into the breast tissue, and could be attached to each other as well (ACS, 2020a; Akram et al., 2017).

Stage III breast cancer is also divided into subcategories IIIA, IIIB, and IIIC.

• Stage IIIA. Stage IIIA cancer is invasive and may be a tumor of any size, may be absent from the breast but found spread to four to nine auxiliary lymph nodes or lymph nodes near the breastbone, or, is invasive cancer that is of any size larger than 5 centimeters and is spread to one to three axillary lymph nodes or lymph nodes near the breastbone (Breastcancer.org, 2018).
• Stage IIIB. In Stage IIIB breast cancer the tumor is larger than 5 centimeters across, has spread to four to nine axillary lymph nodes or to the lymph nodes near the breastbone, is estrogen-receptor-positive (has receptors for estrogen which means cancer cells could be signaled to grow), is progesterone-receptor-positive (has receptors for progesterone which means cancer cells could be signaled to grow), and is HER2-positive (has human epidermal growth factor receptor 2 proteins that can also signal growth) (Breastcancer.org, 2018; Loibl & Giannis, 2017).
• Stage IIIB. In Stage IIIB breast cancer, there may be no tumor found or if present is of any size and may have spread to the chest wall or the skin of the breast and has spread to 10 or more axillary lymph nodes, to lymph nodes above or below the collarbone, or to lymph nodes near the breastbone (Breastcancer.org, 2018).

Stage IV: Stage IV tumors are of any size and have spread to other parts of the body, including the liver, lungs, bones or the brain (Akram et al., 2017; Sun & Zhao, 2017). Of relevance to this dissertation, metastatic breast cancer is stage IV cancer (NBCF, 2019), which spreads in up to five ways:

1. cancer cells invade healthy cells, which then reproduce more cancer cells;
2. cancer cells travel through lymph vessel walls or blood vessel walls to invade the circulatory system or the lymph system, respectively;
3. cancer cells migrate by way of the circulatory system or the lymph system to other parts of the body;
4. cancer cells get lodged in capillaries and stop moving, dividing and migrating into the immediately surrounding tissue where they sit; and/or cancer cells form new, small tumors at the new site called micro-metastases, which perpetuate the process (NBCF, 2019).

Breast cancer that is metastatic commonly transfers to distant organs such as the bones, liver, lungs, and brain—which often accounts for the cancer’s incurability (Sun & Zhao, 2017),.

Breast Cancer Signs and Symptoms

Feng et al. (2018) explain, “Breast cancers can begin in different areas of the breast such as the ducts, the lobules, or the tissue in between” (p. 77). Signs and symptoms of metastatic breast cancer can include a breast lump or lumps; non-lump breast symptoms such as nipple abnormalities and breast pain; and non-breast symptoms such as back pain and weight loss (Koo et al., 2017). However, when metastatic breast cancer has spread to the bones, the liver, the lungs, or the brain, additional symptoms occur: when the metastatic breast cancer has spread to the bones, there may be severe pain, swelling, or breakage to bones (ACS, 2019a; NBCF, 2019). When the metastatic breast cancer has spread to the liver, there may be yellowing of the skin (jaundice), skin itchiness, or skin rash; elevated liver enzymes; and/or stomach pain, loss of appetite, nausea, and vomiting (ACS, 2019a; NBCF, 2019). When the metastatic breast cancer has spread to the lungs, there may be an abnormal chest X-ray, chest pain, chronic (ongoing) coughing, and/or inability to take deep breaths (ACS, 2019a; NBCF, 2019). When the metastatic breast cancer has spread to the brain, there may be persistent, worsening headaches; vision problems, nausea, vomiting, seizures, and/or behavioral or personality changes (ACS, 2019a; NBCF, 2019).

Breast Cancer Screening

Recommendations are made for women for early detection, and when possible cancer is detected, to get breast exams, mammograms, ultrasounds, and/or breast biopsies, and to continue education and research (Akram et al., 2017; Lewis Jr., 2017; Nederlorf, et al., 2019; Scheel et al., 2017; Sun et al., 2017). Mammogram screening is of vital importance, for women with dense breast matter on mammograms have a higher risk, 1.5 to two times higher, than a woman with average breast density (Feng, et al., 2018). Breast cancer screening is considered a life-saving strategy that, combined with treatments, can extend life five or more years for patients who are diagnosed at early stages (ACS, 2019a; Gochett, 2015; Scheel et al., 2017).

Breast Cancer Risk Factors

There are molecular, genetic, and cellular risk factors for breast cancer (Feng et al., 2018; Momenimovahed & Salehiniya, 2018; Sun & Zhao, 2017). Genetic predispositions that create risk factors for breast cancer can include gene mutations in BRCA1 and BRCA2 (genes that make protein that act as tumor suppressors) and inherited mutations in other genes (Feng, et al., 2018; GHR, 2020; Sun & Zhao, 2017). Non-genetic risk factors for breast cancer can include demographics (female gender, age and aging, and possibly even blood type); reproductive factors (age of menarche, late age of menopause, positive family history of breast cancer; race-ethnicity; certain benign breast conditions; and lifestyle and personal behavior-related risk factors (Feng et al., 2018; Hai-Long et al., 2016; Lewis Jr., 2017; Momenimovahed & Salehiniya, 2018; Sun & Zhao, 2017).

Some authorities (e. g., Lewis Jr., 2017; Sun & Zhao, 2017) assert that while women with such risk factors may develop breast cancer more often than others might, having risk factors present does not necessarily mean every woman will develop breast cancer. Nevertheless, as Lewis Jr. (2017) also points out, while some risk factors are unavoidable (genes, family history), other risk factors such as alcohol consumption and dietary fat intake are avoidable risk factors (Prince, 2019). But of specific relevance to this study are demographic risk factors including gender and age and race factors. For instance, Caucasian women are slightly more likely to develop breast cancer than African American women; however, breast cancer among African American women under the age of 45 is more prevalent (Feng, et al., 2018). Furthermore, for African American women, breast cancer death rates are still elevated—despite a decline in all breast cancer death rates—and African American women are more likely to die from breast cancer than are their Asian, Caucasian, Hispanic, and Native-American counterparts (ACS, 2019a; Feng, et al., 2018; Tolson, 2019).

Breast Cancer Survival Rates

Breast cancer is the number one most common cancer in women worldwide (Akram et al., 2017; Feng et al., 2018; Lewis Jr., 2019; Sun, et al., 2018; Tolson, 2019; Zujewski et al., 2018) and is the second leading cause of cancer deaths among women (after lung cancer) (ACS, 2020b; Breastcancer.org, 2018; Tolson, 2019). In 2018, breast cancer accounted for 14.7% of all cancer deaths (Sun, et al., 2018) and in 2020, accounting for about 15.5 percent of all new cancer cases, breast cancer in women accounted for 98.78 % of breast cancer deaths (ACS, 2020c). Relevant to this study, the 5-year relative survival rate of breast cancer patients is about 80%, provided there is early detection. However, the lack of prevention, awareness, and early detection results in a low survival rate of 27% of all women diagnosed with stage IV breast cancer (Sun et al., 2017). Younger women (under 40 years of age) make up 7 % of all breast cancer diagnoses (Brenner et al., 2016), and between 1975 and 2000, the 5-year relative survival rate was 80% among women aged 35–39, 76% among women aged 30–34, 72% among women aged 25–29, and 75 % among women aged 20–25 years (Brenner et al., 2016). But the 2019 survival rate for young women (under 30) with Stage IV breast cancer was only 16 percent, compared with a 97% 5-year survival rate for young women with Stage I breast cancer, an 83% survival rate for young women with Stage II breast cancer, and a 54% survival rate for young women with Stage I breast cancer (DeMarco, 2019). African American women who are younger than 60 years old have higher breast cancer incidence rates and higher mortality rates compared with Caucasian women (ACS, 2019a; Feng, et al., 2018; Richardson et al., 2016; Tolson, 2019). Breast cancer is less likely to be found at an earlier stage among African American women than among Caucasian women (Richardson et al., 2016). Survival rates for African American women with stage IV breast cancer have been found to be lower compared with women of other races (Enewold et al., 2018;). A specific study by Arciero et al. (2017) revealed that African American women have worse overall survival and worse breast cancer cause-specific survival in HR+/HER2− stages III and IV breast cancer and HR−/HER2+ stage IV cancer; they had worse overall survival but not breast cancer cause-specific survival in HR+ /HER2− stage II cancer and HR−/HER2− stage II cancer. Such statistics highlight the need for further research such as that this study will provide.

Standard Medical Treatments for Breast Cancer

Standard or traditional medical treatments typically target the cancer in order to physically treat the patient. These standard medical treatments can include surgery, radiation therapy, hormone therapy, chemotherapy, targeted therapy, and clinical trials.

Surgery

Surgery, either breast conserving surgery that is done to remove the tumor and a margin of healthy tissue that surrounds it (lumpectomy) or surgery that involves the removal of the entire breast (mastectomy), is still the most common treatment for patients diagnosed with breast cancer (Bellavance & Kesmodel, 2016; Johnson et al, 2015; Lewis Jr., 2019). For ductal carcinoma in situ (DCIS) and early-stage invasive breast cancer, physicians typically recommend surgery (Mayo Clinic staff, 2020). Lumpectomy surgery and mastectomy surgery have similar survival outcomes (Mayo Clinic staff, 2020). However, specific to this study, surgical resection of the primary tumor among women with stage IV breast cancer remains controversial (Lane et al., 2019).

Radiation Therapy

Radiation therapy uses high-energy X-ray or proton beams to destroy cancer cells (Mayo Clinic staff, 2020). Radiation therapy after lumpectomy reduces the chance that the cancer will come back (recur) or that it will progress to an invasive form of cancer (Horton et al., 2017; Mayo Clinic staff, 2020). Also reducing the need for mastectomy, radiation therapy is used for the early stages of breast cancer and affects only the cells that are tested, but may be used after breast cancer surgery to destroy the remaining cells in the chest area (Akram et al., 2017; Horton et al., 2017).

Hormone Therapy

Hormone therapy is used only in hormone receptor-positive breast cancers—estrogen-receptor-positive cancer, progesterone-receptor-positive cancer, and HER2-positive cancer (Breastcancer.org, 2018; Loibl & Giannis, 2017; Mayo Clinic staff, 2020). With hormone therapy, hormone-blocking drugs (e. g., tamoxifen for blocking estrogen) prevent the cancer cells from using the body’s natural growth hormones (Breastcancer.org, 2018; Lewis Jr., 2019; Mayo Clinic staff, 2020). Hormone therapy is only used for hormone-positive cancers (ACS, 2019b; Mayo Clinic staff, 2020). A study by Dembinski et al. (2020) showed that hormone therapy has been found to be associated with increased overall survival for up to 10 years of follow up. However, the efficacy of hormone-blocking therapy remains debatable (Dembinski et al., 2020).

Chemotherapy

Chemotherapy is a process of killing cancer cells by using a series of medicines specific to the breast cancer patient, the stage of the cancer, and specific characteristics such as hormone receptor-positive characteristics (Breastcancer.org, 2020). In stage I, stage II, and sometimes stage III cancers, chemotherapy is used post- surgery to remove the cancer by destroying any residual cancer cells and to reduce the risk of the cancer reoccurring (Breastcancer.org, 2020). Chemotherapy is almost always recommended when the cancer has the potential to invade other parts of the body and when the cancer has already spread as it does in stage IV cancer, but is not typically recommended for non-invasive cancer types (Breastcancer.org, 2020).

Clinical Trials

Clinical trials are offered as available experimental treatments that help doctors and researchers test new cancer treatments; test new ways to find, diagnose, and manage cancer; and test ways to prevention cancer (NCI, 2020). The trials consist of subjects with cancer who will receive either the drug/drug combination being tested or no drugs (a placebo). Therefore, clinical trials may or may not be effective in treating the breast cancer and may or may not have additional risk factors (Lewis Jr., 2019).

Alternative Medicine and Treatments

Many women diagnosed with breast cancer also rely on one or more forms of complimentary alternative medicine (CAM) to tend to their physical, cognitive (mental), affective (emotional), social, and/or spiritual health, healing, and well-being. The research by Neuhouser et al. (2016) shows that following diagnosis, approximately 50 to 75 percent of all breast cancer patients use at least one form of CAM. Alternative, non-medical options for treatment of breast cancer are categorized under the complementary and alternative medicine (CAM) heading (Bahall, 2017; Buckner et al., 2018; Eckard Lambe, 2013; Greenlee et al., 2016; Hajian et al., 2017; Johnson et al., 2018; Jones et al., 2019; Lyman et al., 2018; Neuhouser et al., 2016; Ogunkorode, 2019; Porter et al., 2019; Tolson, 2019) and involve alternative medical systems that include 1) Ayurvedic medicine (Cassileth, 2008; Subramani & Lakshmanaswamy, 2017), 2) traditional Chinese medicine (Cassileth, 2008; Porter et al., 2019; Sun et al., 2016), 3) indigenous health practices (Adams, et al., 2015; Gall et al., 2018), 4) naturopathy and homeopathy (Cassileth, 2008; Greenlee et al., 2017; Sharma & Sharma, 2019), and 5) religiousness and spirituality (Akram et al., 2017; Buckner et al., 2018; Cardoso, et al., 2017; Carlson, 2012; Clinton & Hawkins, 2011; Holt et al., 2008; Hulett, 2016; Koenig, 2012; Kuhl, 2015; Levers, 2012; Neuhouser et al., 2016; Paredes & Pereira, 2018; Porter et al., 2019; Puchalski et al., 2012; Roa et al., 2015; Sabado et al., 2010; Salsman, et al., 2015; Sharma et al., 2010; Steinhorn et al., 2017; Tolson, 2019; Williams & Jeanetta, 2016). Each of these systems offer non-medical treatments for the physical, cognitive (mental), affective (emotional), social, and spiritual health, healing, and well-being of patients diagnosed with cancer—such as diet and supplements (such as antioxidants); body, mind, and soul therapies (such as acupuncture, biofeedback, homeopathy, massage, meditation, osteopathy, Reiki, relaxation, therapeutic touch, and yoga) for the treatment of depression, anxiety, and stress (Buckner et al., 2018; Greenlee et al., 2017; Neuhouser et al., 2016; Prince, 2019; Seiler & Jenewein, 2019).

Ayurvedic Medicine

Ayurvedic medicine or Ayurveda originated in India (Cassileth, 2008; Subramani & Lakshmanaswamy, 2017). From the Sanskrit words “ayur” (life) and “veda” (knowledge), Ayurvedic medicine is a holistic approach that focuses on a mind-body system for healing. Ayurveda centers on consciousness, or, mindfulness—achieved through yoga or meditation (Cassileth, 2008; Subramani & Lakshmanaswamy, 2017) and physical cleansing and detoxification (Cassileth, 2008; Subramani & Lakshmanaswamy, 2017). It is not documented how many cancer patients use Ayurvedic clinics and spas for healing (Cassileth, 2008).

Traditional Chinese Medicine

Like Ayurveda, traditional Chinese Medicine (TCM) also takes a holistic approach to healing mind and body and to achieving balance or, harmony (NCCIH, 2013). TCM treatments target underlying patterns of disharmony in each individual patient and are based on three main diagnostic tools and therapeutic modalities: 1) acupuncture, which targets the body’s Chi (life force) that flows through 12 meridians dotted with acupoints) (Zhu, 2014); 2) massage and manipulation; and 3) the wide array of natural ingredients comprising the Chinese Materia Medica, which provides treatments for most human ailments, including cancer (Cassileth, 2008; Porter et al., 2019; Sun et al., 2016). The study by Sun et al. (2016) reveals that treatment of breast cancer using CHM has been described in Chinese medical texts for more than 2,000 years.

Indigenous Health Practices

Traditional indigenous and complementary medicines are also rooted in a holistic approach incorporating physical, cultural and spiritual wellbeing (Adams, et al., 2015; Gall et al., 2018). Indigenous health practices include bush medicine, healers, singing and chanting, and other, external, herbal remedies that indigenous peoples use to connect or re-connect to land, spiritual, and ancestral roots (Gall et al., 2018). While there is a limited research literature on traditional indigenous and complementary medicine use with indigenous cancer patients (Gall et al., 2018), the role of CAM in general has increased for cancer patient issues, experiences, perceived benefits, decision making, and patient-practitioner interaction and communication (Gall et al., 2018).

Naturopathy and Homeopathy

Practitioners of naturopathy and homeopathy also tend to be holistic and based on the use of nature and natural remedies—herbs, botanicals, enzymes, amino acids, vitamins, minerals, etc.—for the treatment of many ailments (Cassileth, 2008).

Naturopathy. Naturopathy is a system of healing that considers illness the result of a body imbalance in the processes the body typically uses to heal itself. Restoring these imbalances is based on modification of diet; use of herbal medicine(s); use of acupuncture, hydrotherapy, and massage; and application of six principles: 1) the healing power of nature; 2) the identification and treatment of the cause of disease; 3) the concept of ‘first do no harm’; 4) the notion of doctor as teacher; 5) the treatment of the whole person; and 6) the prevention of occurrence or recurrence of the disease (Poorman et al., 2001). Naturopathy supports cancer treatment and prevention by boosting and sustaining the immune system, minimizing inflammation after surgery, reducing the side effects of radiotherapy, chemotherapy, and other drug therapies, and, among others, supporting coping with mental and emotional stresses (Rothenberg & Barrett, 2020).

Homeopathy. Homeopathy is also a complete system of medical theory and practice. Based on the law of similars—that like cures like (Hahnemann, in Samuels et al., 2018)—homeopathy is thought to work on physical and psychological levels to “…. restore the body’s ‘vital force’” (Samuels et al., 2018, p. 487). Homeopathy “…uses both ‘low potency’ (i. e., <12C, or a dilution <10⁻²⁴) and ‘high potency’ (i. e., >12C, or a dilution ≥10⁻²⁴), with the former used for acute and physical symptoms, the latter for chronic and psychological symptoms” (p. 487). Homeopathic medicine is increasingly used in the United States for cancer patients, is one of the most popular forms of CAM used for cancer patients in one out of every two European countries, and is gaining popularity for cancer treatment in India and South America (Sharma & Sharma, 2019). However, Samuels et al. (2018) explain, “Because homeopathy uses highly diluted compounds, as well as its homeopathic approach to patient care (vs the allopathic paradigm of conventional medicine), this complementary medicine therapy remains one of the most debated modalities in integrative oncology” (p. 487). Yet, homeopathy is used in cancer diagnosis about 6% of the time and for breast cancer specifically about 24% (Sharma & Sharma, 2019).

Cancer patients have reported several reasons for the use of complementary alternative medicines and therapies including “…increasing one’s chances of survival, alleviating adverse treatment effects, detoxifying the body, boosting immunity, enhancing quality of life, fostering a sense of control, and aiding conventional treatment” Gross, Liu, & Wu, 2016, p. 293). Documentation of the use of CAM therapies for advanced stage cancer ranges from 45 to 88 percent (Gross et al., 2016),

Religiousness and Spirituality

Among the forms of CAM are religiousness and spirituality and the use of faith and prayer. Faith and prayer are the cornerstones of religion and spirituality. Indeed, Lewis Jr. (2017) asserts that faith and prayer are some of the most common forms of CAM. However, as forms of CAM, faith and prayer are not well understood (Buckner et al., 2018; Neuhouser et al., 2016; Porter et al., 2019; Tolson, 2019). This is because the relationship between health and religiousness or health and spirituality is still fairly elusive in the empirical world. Puchalski et al. (2012) assert, “Man is not destroyed by suffering; he is destroyed by suffering without meaning” (p.352). For women with stage IV breast cancer, a cure is not always possible. However, there is a belief that there is room for healing (Puchalski et al., 2012). There is a position that holds that spirituality and practices help allow a cancer survivor to live longer by coping (Puchalski et al., 2012). Patients who are spiritual and have spiritual practices use beliefs in coping with their illnesses and life stressors—leading to depression, anxiety, and stress—that are associated with their breast cancer diagnoses (Ahmadi et al., 2019; Buckner et al., 2018; Burnette, & Lee, 2018; Greenlee et al., 2017; Hajian et al., 2017; Movafagh et al., 2017; Neuhouser et al., 2016; Puchalski et al., 2012; Seiler & Jenewein, 2019). It is noted that spirituality is an essential part of life (Clinton & Hawkins, 2011; Puchalski et al., 2012). Spiritual commitment tends to enhance recovery from illness and surgery; it results in higher levels of self-esteem (Clinton & Hawkins, 2011; Puchalski et al., 2012).

Aspects of Spiritual Care

There are specific aspects of spiritual care that help the breast cancer survivor after her diagnosis of breast cancer. The research lists these aspects, which include practicing compassionate presence; listening to patients/clients fears, hopes, pain, and dreams; obtaining a spiritual history; being attentive to all dimensions of patients and their families to include their faith; when appropriate, incorporate and integrate spiritual practices with the patient/client Clinton & Hawkins, 2011; Holt, Lee, & Wright, 2008; Hosseini et al., 2016; Hulett, 2016; Jim et al., 2015; Koenig, 2012; Movafag et al., 2017; Park et al., 2015; Park, Waddington, & Abraham, 2018; Pearce et al., 2018; Peteet & Balboni, 2013; Ripamonti, 2018; Roa, Sibbett, Phillips, & Hickman, 2015; Roh et al., 2018; Sabado et al., 2010; Salsman, et al., 2015; Steinhorn et al., 2017; Wright, 2019; Xing et al., 2018). It is important to note that there is a link between spirituality, health, and healing, which is well-established since contemporary spirituality is marking its territory in today’s healthcare arenas (Puchalski et al., 2012). It is imperative that the counselor or caregiver emphasize the importance of spiritual care and the spiritual needs of the patient/client (Puchalski et al., 2012).

Faith and Breast Cancer Treatment

Faith is an important element in the guidance of most aspects of the lives of Christians, who make up 79.5% of the American population (Lewis Jr., 2017). But faith is also considered a powerful resource that alleviates stress and brings real comfort, which can be effective in adaptation with and return to life (Brown & Cowart, 2018; Clinton & Hawkins, 2011; Lewis Jr., 2017; Nakane & Koch, 2017; Roh et al., 2018; Saunders et al., 2017). Deuteronomy 31:6 states, “Be strong and bold; have no fear or dread of them, because it is the Lord your God who goes with you; he will not fail you or forsake you” (New International Version). The research is limited on actual faith of breast cancer survivors; however, faith is a part of the healing process of women who have been diagnosed with breast cancer (Clinton & Hawkins, 2011).

The Use of Prayer in Breast Cancer Treatment

The use of prayer or spiritual healing in the United States indicates 64.1% of communities use prayer (Roa et al., 2015). Roa et al. (2015) elaborate, saying, “…spiritual healing is systematic and purposeful intervention by one or more persons aimed to help another person by focused intention to improve their condition” (p. 1). The research has shown that spirituality plays a prominent role in the lives of most palliative patients whether they adhere to a specific religion or belief (Steinhorn et al., 2017). Focused hope with prayer centers on the cure of the cancer, which is on a different spectrum of intrinsic hope, which offers a more realistic and resilient emotional foundation (Steinhorn et al., 2017).

The Use of Spiritually-based Support in Breast Cancer Treatment

A spiritual support team, which could include church leaders and members, family, and/or friends, can make a difference in the overall quality of life for the breast cancer survivor (Akram et al., 2017; Mclaughlin et al., 2016; Sabado et al., 2010; Sharma et al., 2010). For example, the incorporation of spiritually-based content into church-based breast cancer education could be a promising health approach for women (Brown & Cowart, 2018; Clinton & Hawkins, 2011; Holt et al., 2008; Koenig, 2012; Kuhl, 2015). Other research points out that spirituality supplies considerable emotional and logistical assistance to survivors and their support team (Sabado et al., 2010). The use of spirituality for guidance and coping affects the quality of life for the cancer survivor as well as for the support team (Sabado et al., 2010),. Other studies reiterate that support is an important role and multi-dimensional need that should frequently be provided to client of breast cancer, which impacts the entire family and can cause a disruption in the daily lives of the caregivers (Williams & Jeanetta, 2016).

Conceptual Framework

Schreiber and Edward (2015) assert, “Religion and spirituality are much studied coping mechanisms; however, their relationship to changes in behaviors, relationships, and goals is unclear” (p. 612). Given the focus of this study is on faith and prayer for women with stage IV breast cancer, the pursuit of theory on behavior changes (and decision making) was deemed necessary. In addition, it was considered necessary to take into account more than just patient demographics and physical needs and instead to include demographic, cognitive, social and personality trait factors that inform cancer patient CAM form decision making. Therefore, the conceptual models used to frame this study are 1) Balneaves et al.’s (2012) complementary and alternative medicine (CAM) decision-making process model and 2) Chowdhuri and Kundu’s (2020) CAM modality integrated decision-making model. In this study, both of these are based on Montbriand’s (1995) decision tree model describing alternate health care choices made by oncology patients.

General Patient CAM Decision Making

Several authorities (e. g., Balneaves et al., 2012; Chowdhuri & Kundu, 2020; Jones et al., 2019; Weeks et al., 2014) have outlined patient decision-making regarding CAM use. In such models, patient behavior is explained as covering three phases: early, middle, and late. The early phase of CAM decision-making begins when the cancer is diagnosed; the middle phase supports a decided-upon CAM protocol based on the belief, needs, and unique experiences of the individual cancer patient; and the late phase occurs as the individual cancer patient becomes a survivor. In general, the CAM decision making for the cancer patient involves four behaviors: 1) taking stock of the [alternative] treatment options; 2) gathering and evaluating cam information; 3) making CAM decisions; and 4) revisiting the CAM decision (Balneaves et al., 2012, p. 74). Figure 1 below demonstrates.

As Balneaves et al.(2012) explain, “Unlike many rational treatment decision-making models presented within the health care literature, the CAM decision-making process has been described as a dynamic and iterative process that is highly variable across individuals” (p. 74).

Decision-making Factors for Cancer Patients

The four-phase process outlined by Balneaves et al. (2012) includes social, demographic, disease-related, psychological, and social factors that influence cancer patients’ CAM decision-making. In addition to going through phases of CAM decision making, cancer patients have been recognized for what factors affect their CAM form decision making. Chowdhuri and Kundu (2020) take into account demographic, cognitive, social, disease burden, and personality trait factors that influence treatment decisions. These factors contribute to cancer patient behavior that in turn affects outcomes of well being and quality of life (Akram et al., 2017; Levers, 2012). Characterized by Akram et al. (2017), the individual’s perception of her position in life in the context of the culture and value systems in which she lives and in relations to her goals, expectations, standards, and concerns. Improvement and sustenance of quality of life of breast for cancer patients is the primary objective of medical and therapeutic carers. The CAM decision-making models reflect the complex, interactive, integrated process for patients diagnosed with breast cancer who turn to traditional medicine to target the cancer and treat the physical body but who also rely on one or more forms of complimentary alternative medicine (CAM) to tend to their physical, cognitive (mental), affective (emotional), social, and/or spiritual health, healing, and well-being.

Related Literature

Partial answers to the research questions guiding this study can be found in some of the current research literature. Three themes are reflected: 1) the influence of breast cancer stage diagnosis on choice of treatment options (Bellevance & Kesmodal, 2016; Gochett, 2015; Hawley et al., 2016; Lane et al., 2019; McVeigh & Kerin, 2016; Youl et al., 2019; Hawley et al., 2016), 2) forms of complimentary alternative medicine (CAM) used by breast cancer survivors (Bahall, 2017; Buckner et al., 2018; Eckard Lambe, 2013; Gall et al., 2018; Greenlee et al., 2016; Johnson et al., 2018; Jones et al., 2019; Neuhouser et al., 2016; Ogunkorode, 2019; Porter et al., 2019; Sun et al., 2016; Tolson, 2019), and 3) the effects of faith and prayer on health (Ahmadi et al., 2019; Buckner et al., 2018; Burnette, & Lee, 2018; Carlson, 2012; Clinton & Hawkins, 2011; Greenlee et al., 2017; Hajian et al., 2017; Hulett, 2016; Neuhouser et al., 2016).

Influence of Breast Cancer Stage Diagnosis on Choice of Treatment Options

Some researchers maintain, “[Breast cancer] tumor characteristics, including tumor size, lymph node involvement, and stage, have all been shown to influence treatment decisions…” (Bellevance & Kesmodal, 2016), para. 9). However, while research into how stages of breast cancer influence treatment decisions for all stages and for all treatment modes is scarce, some researchers have investigated certain treatment decision-making factors (Gochett, 2015; Hawley et al., 2016; Lane et al., 2019; McVeigh & Kerin, 2016; Youl et al., 2019).

Some research has focused on treatment decisions for patients with early-stage (I or II) breast cancer. For instance, Hawley et al. (2016) found that patients newly diagnosed with early stage breast cancer face a series of complex decisions across the continuum of their care. Loco-regional treatment plans are typically the first, most difficult, and perhaps most significant decisions they make, because the decision will be based on either breast conservation therapy (lumpectomy with radiation) or total breast removal treatment (mastectomy). When the treatment option was surgery such as mastectomy, Youl et al. (2019) noted breast cancer surgery eligibility depended upon several factors—clinical factors (including stage, tumor size, grade, previous history of breast cancer or breast disease) and non-clinical factors (including age, socioeconomic status and geographical location).

Other research has focused on treatment decisions for patients with stage IV breast cancer, which, to an extent, is relevant to this study. For example, Lane et al. (2019) conducted a study with 24,015 women with breast cancer. The researchers reported that of the total number of participants, 13,505 women (56.2%) underwent systemic therapy alone and 10,510 women (43.8%) underwent surgical resection. The authors noted that, “Treatment with systemic therapy before surgery was associated with larger tumor size…” (p. 537). Other research includes treatment decisions for specific stages and characteristics –such as ER positive early-stage breast cancer—while pointing out the importance of getting proper care for severe stages but avoiding that same treatment and sparing the fallout of intensive traditional treatment for low-risk patients (McVeigh & Kerin, 2016). For instance, McVeigh and Kerin (2016) write,

Implementation of the Oncotype DX assay has led to a change in the manner in which chemotherapy is utilized in patients with early stage, estrogen receptor (ER)-positive, node-negative breast cancer; ensuring that patients at highest risk of recurrence are prescribed systemic treatment, while at the same time sparing low-risk patients potential adverse events from therapy unlikely to influence their survival (p. 393).

Similarly, Gochett (2015) studied the factors that influence transition from primary treatment to early survivorship for 56 middle-aged Caucasian breast cancer survivors who were diagnosed at an early stage and who had opted for treatment with either radiation therapy alone, chemotherapy alone, or combined treatment modality with both radiation therapy and chemotherapy. While the research focused on transitioning factors, the researcher did discuss psychological well being that was important in terms of survivors being engaged in activities of life associated with being independent, having a purpose in life, self-acceptance, personal growth and development, having positive relationships with others, and mastering one’s environment. The findings imply that choices made are based on such factors that go beyond physical well-being alone.

Forms of Complimentary Alternative Medicine (CAM) Used by Breast Cancer Survivors

A good amount of research has been done to discern what forms of CAM have been used by women diagnosed with breast cancer (Bahall, 2017; Buckner et al., 2018; Eckard Lambe, 2013; Gall et al., 2018; Greenlee et al., 2016; Johnson et al., 2018; Jones et al., 2019; Neuhouser et al., 2016; Ogunkorode, 2019; Porter et al., 2019; Sun et al., 2016). Much of the research was acknowledged earlier in this chapter, but evidence-based literature should be further discussed.

A daunting report was made by Johnson, Park, Gross, and Yu (2018), who studied refusal of conventional cancer therapy and survival among 1,901,815 patients from 1,500 Commission on Cancer–accredited centers across the United States who were diagnosed with [curable ] non-metastatic breast, prostate, lung, or colorectal cancer. The researchers found that of those patients who received traditional cancer treatment and also used CAM, the ones who received traditional cancer treatment and CAM but refused additional traditional cancer treatment had a higher risk of dying. However, a study by Neuhouser et al. (2016) revealed that of 707 women diagnosed with stage I-IIIA breast cancer, 60.2% reported using one or more forms of CAM post-diagnosis. Of all 707 women in the study, only 70 breast cancer-specific deaths were reported. The most commonly chosen form of CAM (chosen by 51%) was natural products, 42% of whom also chose plant-based estrogenic supplements (42%). 27 % of participants chose manipulative and body-based practices and 13% chose alternative medical systems. However, there were no connections made between CAM use and breast cancer-specific mortality.

Greenlee et al. (2016) focused a study on breast cancer treatment initiation and adherence using combined chemotherapy and CAM. To determine whether CAM use is associated with decreased breast cancer chemotherapy initiation, the team recruited and interviewed 685 women under the age of 70 who had been diagnosed with non-metastatic invasive breast cancer from Columbia University Medical Center, Kaiser Permanente Northern California, and Henry Ford Health System. Focused on five forms of CAM (vitamins and/or minerals, herbs and/or botanicals, other natural products, mind-body self-practice, mind-body practitioner-based practice), the researchers found that a) 598 women (87%) reported CAM use at baseline; b) when chemotherapy was indicated, 272 women (89%) initiated chemotherapy, compared with when chemotherapy was discretionary and 135 women (36%) initiated chemotherapy; c) when chemotherapy was indicated, dietary supplement users and women with high CAM index scores were less likely than nonusers of dietary supplements to initiate chemotherapy; d) there was no significant relationship between mind-body practices usage and chemotherapy initiation; and e) there was no significant relationship between CAM use and chemotherapy initiation when chemotherapy was discretionary.

Some studies were focused on one form of CAM or one alternative medical system, such as traditional Chinese medicine: Porter et al. (2019) conducted studies with a focus on Chinese herbal medicine, specifically in the treatment of hot flashes and night sweats that are a side-effect of breast cancer endocrine therapy. To collect qualitative data including narrative data of women’s experiences of hot flashes and night sweats and results from participating in a Chinese Herbal Medicine (CHM) trial to alleviate the side-effects, the researchers conducted semi-structured focus groups with eight breast cancer survivors. Analysis of quality of life data and data related to the acceptability and feasibility of CHM as a management option for hot flashes and night sweats revealed women disliked tastes but were motivated to reduce side effects of endocrine therapy; and that despite the psychosocial and physiological implications of side effects, women were motivated to “…‘give it [CHM] a go’, [while struggling with] ‘avoidance and acceptance’, ‘routine and reward’, and the ‘transitioning to survivorship’” (n. p.).

Bahall (2017) studied who, among all cancer patients, used some form of CAM. Of the cross-sectional, convenience sample of 350 patients from the Oncology Department of San Fernando General Hospital in Trinidad and Tobago, 138 (39.6%) had been diagnosed with breast cancer. So among the 137 patients who used at least one form of CAM, it could be concluded that a little over half of these women (about 54 women), as breast cancer patients, used at least one form of CAM. Important reasons for CAM use were reported by breast cancer patients (n) as including a) disappointment with conventional medicine (11); b) conventional medicine being too toxic/damaging (4); c) CAM was more aligned with the patient’s personal belief systems (38); d) the patient desired taking control of her own treatment (20); e) conventional medicine lacked the personal touch (4); the patient wanted to try everything that would help (45); and f) conventional medicine was too expensive (32). Consistent with the themes of this study, the findings regarding reasons for using forms of CAM are led in three areas: cost, taking control of one’s own treatment, and having treatment that aligns with personal belief systems. Moreover, of all patients who used one or more forms of CAM, breast cancer patients in this study were, along with prostate cancer patients, they were the group responding they were satisfied-to-very satisfied with CAM results more than any other groups.

A few studies have been done to consider the use of faith, religion, spirituality, and prayer in the post-cancer diagnosis phases. For example, Ogunkorode (2019) conducted a study with Nigerian women who seek “divine intervention”, given their mistrust of standard medicine. To investigate health-seeking behaviors of women with advanced-stage breast cancer and to examine factors that motivate their specific health-seeking behavior, the researcher recruited and interviewed 30 Southwestern Nigerian women diagnosed with advanced stage breast cancer. The findings revealed five themes—1) that breast cancer is life-threatening and few survive it, 2) that breast cancer is inflicted by the enemy, 3) that support is crucial, 4) that major barriers prevent seeking help, and 5) that making decisions of seeking help for cancer amount to a distrust, on the part of the cancer victim and her family, of traditional medicine. The researcher concluded that 20 participants (67%) opted for divine intervention and that turning to religion and using their strong faith in God’s ability to see them through the advanced stages of breast cancer is an emotional, psychological, social, physical, and experiential coping mechanism.

Effects of Faith and Prayer on Health

Spiritually based interventions could help the woman who has been diagnosed with breast cancer with mindfulness-based reduction, prayer, mediation, and religious coping (Ahmadi et al., 2019; Buckner et al., 2018; Burnette, & Lee, 2018; Carlson, 2012; Clinton & Hawkins, 2011; Greenlee et al., 2017; Hajian et al., 2017; Hulett, 2016; Movafagh et al., 2017; Neuhouser et al., 2016; Puchalski et al., 2012). The literature emphasizes that religious coping has shown association with spiritual/faith growth, which results in better mental health and positive outcomes following breast cancers (Ahmadi et al., 2019; Buckner et al., 2018; Burnette, & Lee, 2018; Carlson, 2012; Clinton & Hawkins, 2011; Greenlee et al., 2017; Hajian et al., 2017; Hulett, 2016; Neuhouser et al., 2016). Among the most common reported psychosocial interventions in breast cancer literature is mindfulness-based stress reduction and mindfulness-based cognitive therapies which have become significant as an alternative for post-cancer treatment-related symptoms (Hjeltnes et al., 2015; Hulett, 2016; Lancaster et al., 2016; Paredes & Pereira, 2018; Pearce et al., 2018; Sapolsky, 2004; Slavich, 2016). Furthermore, spirituality is an essential ingredient of person-centered care and is considered a critical element in the ways patients with breast cancer cope with illness, diagnosis, and treatment (Puchalski et al., 2012).

Moreover, some recent research has been done to consider the effect(s) of dimensions of religion such as faith and prayer, as forms of CAM, on physical, mental, emotional, and/or social health domains (Ahmadi et al., 2019; Hosseini et al., 2016; Lewis Jr., 2017; Nakane & Koch, 2017; Park et al., 2015; Roh et al., 2018; Mclaughlin et al., 2016; Sajadi et al., 2018; Saunders et al., 2017).

Park et al. (2015) conducted a comprehensive meta-analysis to investigate whether there is a relationship between a) the beliefs, feelings, and practices of religion/spirituality and b) the physical, mental, and social health of cancer survivors. After a quantitative synthesis of their findings, the researchers identified three dimensions of religion/spirituality (cognitive, affective, and behavioral) and the impact on three health domains (physical, social, and mental): the cognitive (and “other”) dimension of religion/spirituality consistently related to physical, mental, and social health. The behavioral dimension of religion/spirituality had a small association with social health and was not significantly related to physical or mental health. The affective dimension of religion/spirituality more strongly impacted mental health outcomes and was also noted as significantly related to physical and social health.

Hosseini et al. (2016) conducted a study of the Islamic perspective of the effectiveness of spiritual intervention on physical and psychological (bio-psychological) health in breast cancer patients. The researchers collected blood samples from 57 volunteer females with early breast cancer before and after spiritual intervention (prayer, patience, reliance, self-sacrifice and forgiveness, altruism and kindness, remission and repentance, thankfulness, zikr (mantra), meditation, and death concepts backed by the Quran, Islam, and international standards emphasizing peace, human growth and perfection, accepting God as an eternal source of power and kindness) to build trust and reduce stress, in order to analyze the changes in dopamine gene receptor expressions as the main site of effect. The researchers found that peripheral blood mononuclear cell samples analyzed by real time-PCR showed significant reduction in dopamine gene receptor (DRD1-5) expressions, compared against baseline/pre-test scores and the control group scores. They concluded,

Spiritual intervention based on Islamic principals can bring back mental health, increase hope and quality of life and eventually change dopamine gene receptor expressions resulting in reduction of cell proliferation, thus better prevention and management in breast cancer patients compared to other forms of treatment (p. 930).

Ahmadi et al. (2019) also studied Islamic religion and mental health (meaning-making coping) with cancer patients in Malaysia. The researchers also emphasized the influence of culture on coping method choice. Interviews with 29 Malay patients, ages 29 to 60 and with up to 25 years of survival longevity from different types of cancer, uncovered four kinds of coping resources, including (1) relying on transcendent power, (2) supernatural or mystical beliefs, (3) finding oneself in relationships with others, and (4) nature. The researchers concluded that strong Islamic culture has a strong impact on coping methods and ways of looking at being cancer patients.

Nakane and Koch (2017) also studied faith and religiosity and the impact on spiritual well-being, as indicated by coping with breast cancer. Following interviews with 28 breast cancer patients who also completed a Spiritual Well-Being Scale, the researchers found spiritual well-being was positively associated with spirituality/religiosity as it lent to a) acceptance of diagnosis, b) treatment adherence, and c) future prospects for the patient diagnosed with breast cancer. The researchers concluded that faith and religiosity “…present themselves as the determinant, potent, and active factors in their clinical treatments and in their lives” (p. 103).

Sajadi et al. (2018) also investigated the spiritual well-being of cancer patients as it is influenced by spiritual counseling. Conducting a randomized clinical trial with 42 female cancer patients in Iran, the researchers implemented either eight weeks of a spiritual counseling intervention (for 21 participants) or routine education and care (for the control group of 21 participants) and assessed spiritual well-being using the Spiritual Well-Being Scale. Findings included that at baseline before the intervention, there were no significant difference in scores for religious well-being and existential well-being, but following intervention, there was a significant difference between the two groups’ scores in all three subscales—religious, spiritual, and existential well-being. The researchers concluded that spiritual counseling does have a significant, positive impact on spiritual well-being in Iranian women diagnosed with breast cancer.

Roh et al. (2018) also studied prayer and faith as it lent to spiritual coping for Native American or, American Indian, women who were survivors of cancer. The researchers conducted a qualitative study with a community-based participatory research design with 43 American Indian women survivors of breast cancer (n = 14) cervical cancer (n = 14), and colon and other types of cancer (n = 14). The researchers found a) that prayer was an important part of cancer coping and recovery for 32 (76%) of the women in the study and b) that faith was an important part of cancer coping and recovery for 15 (36%) of the participants. The research findings led them to conclude that spiritual faith and traditions provided women with cancer a great source of comfort, strength, hope, and relief.

Summary

Women diagnosed with breast cancer turn to traditional medicine to target the cancer and treat the physical body. But many women diagnosed with breast cancer also rely on one or more forms of complimentary alternative medicine (CAM) to tend to their physical, cognitive (mental), affective (emotional), social, and/or spiritual health, healing, and well-being. Among these forms of CAM are religiousness and spirituality and the use of faith and prayer. This chapter comprised a review of the literature. The research questions guiding the study were identified as follows: 1) How do stages of breast cancer diagnosis influence the choice of faith and prayer as the sole explicit forms of complimentary alternative medicine (CAM)? 2) What draws a breast cancer patient to faith and prayer as explicit forms of CAM?and 3) How do faith and prayer, as forms of complimentary alternative medicine (CAM), affect physical, mental, emotional, and social health?

A conceptual framework for the study was discussed which included two conceptual models used to frame this study: 1) Balneaves et al.’s (2012) complementary and alternative medicine (CAM) decision-making process model and 2) Chowdhuri and Kundu’s (2020) CAM modality integrated decision-making model. These models were chosen to align with the research on faith and prayer for women with stage IV breast cancer, as theory on behavior changes (and decision making) was considered imperative and necessary to taking into account more than just patient demographics and physical needs by including demographic, cognitive, social, and personality trait factors that inform cancer patient CAM form decision making as well.

A review of the related literature was performed that revealed research supporting each of the three major themes in the research questions: 1) the influence of breast cancer stage diagnosis on choice of treatment options (Bellevance & Kesmodal, 2016; Gochett, 2015; Hawley et al., 2016; Lane et al., 2019; McVeigh & Kerin, 2016; Youl et al., 2019; Hawley et al., 2016), 2) forms of complimentary alternative medicine (CAM) used by breast cancer survivors (Bahall, 2017; Buckner et al., 2018; Eckard Lambe, 2013; Gall et al., 2018; Greenlee et al., 2016; Johnson et al., 2018; Jones et al., 2019; Neuhouser et al., 2016; Ogunkorode, 2019; Porter et al., 2019; Sun et al., 2016; Tolson, 2019), and 3) the effects of faith and prayer on health (Ahmadi et al., 2019; Buckner et al., 2018; Burnette, & Lee, 2018; Carlson, 2012; Clinton & Hawkins, 2011; Greenlee et al., 2017; Hajian et al., 2017; Hulett, 2016; Neuhouser et al., 2016). The recent and related research yielded some important findings that lead to significant conclusions—1) that the stage of the cancer may influence decisions regarding the use of one or more forms of complementary alternative medicine (CAM); 2) that the use or combined use of CAM therapies and forms may help to reduce side effects of traditional medical treatments for breast cancer; and 3) that religion and spirituality, including faith and prayer and involving the breast cancer patient’s attitudes, values, beliefs, and practices, have been evidenced to be positively associated with the breast cancer patient’s physical, mental, emotional, social, and spiritual well-being.

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