Introduction: Cancer presents overwhelming challenges for patients and their families, introducing significant uncertainty, loss, and life disruption. This profound experience can deeply affect their sense of meaning in life (MiL), a fundamental human need intrinsically linked to purpose and direction. This study undertakes a Meaning Comparative approach, aiming to investigate and compare the meaning in life (MiL) between individuals diagnosed with cancer and their close family members.
Methods: A descriptive comparative study design was employed, involving 400 participants – cancer patients and their family members – recruited from university hospitals in Tabriz and Ardebil provinces, Iran. Participants were selected using convenience sampling. Data collection was performed using the Life Evaluation Questionnaire (LEQ), and analysis was conducted using descriptive and inferential statistics with SPSS version 13 software.
Results: The study revealed a notable difference in MiL scores. Cancer patients exhibited a mean MiL score of 119 (SD=16.92), while their family members scored significantly higher at 146.2 (SD=17.07). Statistical analysis confirmed a significant difference in MiL between the two groups.
Conclusion: The findings highlight a lower sense of meaning in life among cancer patients compared to their family members within the Iranian context. This disparity underscores the critical need for enhanced attention to psychological support and interventions within Iranian healthcare systems to address the existential concerns of cancer patients.
Keywords: Meaning in Life, Comparative Study, Cancer, Patients, Family Members, Psycho-oncology
Introduction
Cancer remains a leading global health crisis, contributing significantly to both morbidity and mortality. Worldwide statistics indicate approximately 14 million new cancer diagnoses and 8.2 million cancer-related deaths in 2012.1 Projections estimate a rise in new cancer cases from 11 million in 2002 to 16 million by 2020 globally, affecting both developed and developing nations.2 By 2030, it is anticipated that 70% of all cancer diagnoses will occur in adults aged 65 and older.3 In Iran, cancer is a major public health concern, identified as the third leading cause of death, following cardiovascular diseases and traffic accidents, according to recent reports from the Iran Ministry of Health.4 Earlier research estimated cancer incidence rates across Iran at 134 per 100,000 men and 121 per 100,000 women. Furthermore, cancer incidence is projected to increase substantially in the coming decade due to rising life expectancy and population aging.5
For individuals facing cancer, as with other chronic illnesses, the primary goal of care is to optimize quality of life (QOL). A significant factor influencing QOL is the individual’s meaning in life (MiL) and their understanding of life’s purpose.6 While various definitions of MiL exist, it is broadly understood as a multi-faceted construct encompassing beliefs that provide coherence to the world and imbue personal life with purpose.7 More generally, MiL is defined as an individual’s subjective sense of meaningfulness, encompassing a sense of purpose or direction, comprehension of life circumstances, and personal significance.8
The concept of MiL gained prominence through the work of Viktor Frankl, an Austrian psychiatrist and Holocaust survivor. Frankl defined “meaning” as the realization of values rooted in creativity, experience, and attitude. His logotherapy emphasizes the human capacity to endure suffering when meaning is found within it.9 This perspective is particularly relevant in clinical and healthcare settings, especially for patients facing severe illnesses or end-of-life situations.10 Cancer, for example, profoundly challenges a patient’s MiL, introducing uncertainties about mortality and recurrence, accompanied by diverse losses including health, employment, social connections, and the normalcy of life.11
LeMay and Wilson highlighted “meaning” as a central concern, potentially causing significant distress for end-of-life patients. Unaddressed, this existential distress can negatively impact psychosocial well-being and QOL, increasing anxiety, depression, suicidal ideation, and diminishing the will to live.12 Researchers advocate for the integration of MiL assessment and interventions in the care of patients with advanced-stage cancer.13
Empirical studies consistently identify MiL as a crucial element for maintaining and enhancing physical, psychological, and mental health, often linked to having a goal or a unified sense of purpose.14–16 Literature reviews distinguish between meaning as comprehending an adverse event and its causes – typical in the initial stages of experience – and meaning as understanding the philosophical, spiritual, and existential implications of traumatic experiences, more common in later stages.17 While both perspectives are valid, this study focuses on the latter, viewing MiL as being cultivated through interpersonal relationships and cultural context.8
Research has demonstrated that seeking and achieving MiL serves as a vital protective factor against emotional instability for both cancer patients and their families, promoting psychological health and well-being.18, 19 Comparing MiL between cancer patients and their family members is crucial for healthcare professionals to develop targeted and effective support services. Despite the recognized importance of fostering MiL in this population and raising awareness among Iranian healthcare professionals regarding spiritual and palliative care, research addressing this critical issue within the Iranian context remains limited. A comprehensive understanding of such comparisons is essential for healthcare providers to deliver appropriate care to both cancer patients and their families. Therefore, this study aimed to conduct a meaning comparative analysis of MiL between cancer patients and their family members within the specific cultural context of Iran.
Materials and methods
This descriptive meaning comparative study was conducted in hematology-oncology units of university hospitals in Tabriz and Ardebil, two provinces in northwest Iran, from April to June 2015. The study population included all patients and their family members visiting these centers during the study period. Inclusion criteria were: (a) confirmed cancer diagnosis for the patient or their family member; (b) age 18 years or older; (c) willingness to participate; (d) at least 3 months post-diagnosis; and (e) ability to communicate verbally. Participants were excluded if they had chronic diseases other than cancer (e.g., diabetes, COPD), experienced significant disease worsening requiring ICU transfer, had a diagnosed mental illness, or withdrew from the study.
Sample size calculation was based on a pilot study involving 40 cancer patients and their family members. Using G*Power 3.1.2 software, a two-tailed t-test for comparing means of MiL between two independent groups (patients and family members) was performed. Input parameters included an alpha level (α) of .05, effect size (d) of 0.285, power of 0.8, and a 1:1 ratio between groups. This calculation indicated a required sample size of 390 participants. To account for potential attrition and incomplete questionnaires, a convenience sample of 430 participants (cancer patients and family members) was invited, following ethics review board recommendations. Ultimately, 400 eligible participants (200 patients and 200 family members) completed and returned questionnaires, yielding a 93% response rate.
Data collection utilized a two-part questionnaire. Part one collected demographic data, and part two comprised the Life Evaluation Questionnaire (LEQ).20 The LEQ, a multidimensional instrument developed by Salmon et al. (1996), assesses meaning in life through 44 items across five subscales: freedom versus restriction,10 appreciation of life,5 contentment,8 resentment,13 and social integration.8 Items are rated on a 5-point Likert scale (1=strongly disagree to 5=strongly agree). Total scores range from 44 to 220, with higher scores indicating greater MiL. The LEQ was translated into Persian following established guidelines. Two independent forward translations by native English speakers fluent in Persian produced an initial English consensus version. Subsequently, two independent backward translations of the consensus English version were conducted by bilingual native Persian speakers with English degrees, unfamiliar with the original Persian version. The authors reviewed these backward translations to ensure accuracy and fluency of the Persian version, making revisions as needed. Content and face validity were confirmed by a panel of 15 faculty members from Tabriz University of Medical Sciences (9 MSc in Nursing, 4 PhD in Nursing, 2 Hematology-Oncology subspecialists). Minor modifications were made based on expert feedback. The final instrument was pilot-tested on 40 cancer patients and family members, yielding Cronbach’s alpha coefficients of 0.87 and 0.9, respectively. A researcher visited hospital wards and clinics to identify eligible participants, distribute questionnaires, instruct participants to complete them privately, and collect completed questionnaires.
The study received approval from the Institutional Review Board (IRB) and the regional Ethics Research Committee (ERC) of Tabriz University of Medical Sciences (No: 5/4/1822). Permissions were also obtained from hospital officials and ward managers. Participants received explanations of the study objectives and provided written informed consent before questionnaire administration. Anonymity and confidentiality were assured.
Data analysis involved descriptive statistics (frequency, percentage, mean, standard deviation) and inferential statistics (Student’s t-test, ANOVA) using IBM SPSS Statistics software (version 13; SPSS, Chicago, IL). Statistical significance was set at p < 0.05.
Results
The mean age of participants was 45.48 years (SD=11.23). The majority were married and reported income less than expenses. Women comprised 55% of the sample (Table 1). Significant differences were found in mean MiL scores between cancer patients (M=119, SD=16.92) and family members (M=146.2, SD=17.07; p<0.001). Table 2 presents a detailed comparison of MiL dimensions between the groups. Within both groups, women had lower mean MiL scores than men. Married individuals exhibited the highest mean scores, while widowed participants had the lowest. MiL scores appeared to increase with higher household income. However, occupational status showed no significant differences, although governmental staff had higher mean scores in both groups (Table 3).
Table 1. Demographic characteristics of the participants.
| Variable | Patients N (%) | Family members N (%) |
|---|---|---|
| Gender | ||
| Female | 109 (54.5) | 111 (55.5) |
| Male | 91 (45.5) | 89 (44.5) |
| Marital status | ||
| Single | 34 (17) | 14 (7) |
| Married | 156 (78) | 180 (90) |
| Divorced/separated | 10 (5) | 2 (1) |
| Widowed/widower | – | 4 (2) |
| Education | ||
| Illiterate | 26 (13) | 16 (8) |
| Primary | 38 (19) | 31 (15.5) |
| Elementary | 61 (30.5) | 36 (18) |
| High school/diploma | 46 (23) | 75 (37.5) |
| University education | 29 (14.5) | 42 (21) |
| Occupational status | ||
| Self-employed | 66 (33) | 62 (31) |
| Handworker | 30 (15) | 19 (9.5) |
| Governmental staff | 30 (15) | 22 (11) |
| Housewife | 74 (37) | 97 (48.5) |
| Place of living | ||
| City | 148 (74) | 166 (83) |
| Village | 52 (26) | 34 (17) |
| Financial status | ||
| Income more than expense | 14 (20) | 12 (40.5) |
| Income less than expense | 146 (73) | 107 (53.5) |
| Income equal to expense | 40 (10) | 81 (6) |
| Type of cancer | ||
| Blood | 86 (43) | —- |
| Gastro-intestinal | 58 (29) | —- |
| Breast | 5 (2.5) | —- |
| Lung and bronchus | 23 (11.5) | —- |
| Others | 28 (14) | —- |
| History of chemotherapy | ||
| Yes | 193 (96.5) | — |
| No | 7 (3.5) | — |
| History of radiotherapy | ||
| Yes | 14 (7) | — |
| No | 186 (93) | — |
| Age (years)* | 47.3 (11.7) | 43.5 (10.8) |
| Time passed since awareness of diagnosis (months)* | 4.3 (0.6) | 4.7 (0.5) |
*Mean (Standard Deviation)
Table 2. Comparison of MiL between patients with cancer and their family members.
| Dimensions of mil | No. of items | Range of score | Participants’ group | P-value |
|---|---|---|---|---|
| Mean (SD) α | Mean (SD) β | |||
| Freedom versus restriction | 10 | 10-50 | 26.64 (7.29) | 28.57 (5.73) |
| Appreciation of life | 5 | 5-25 | 13.09 (3.17) | 14.54 (2.84) |
| Contentment | 8 | 8-40 | 20.37 (4.71) | 23.49 (4.43) |
| Resentment | 13 | 13-65 | 37.21 (8.68) | 39.94 (7.11) |
| Social integration | 8 | 8-40 | 14.11 (4.54) | 15.38 (4.85) |
| Total | 44 | 44-220 | 111.99 (15.58) | 146.2 (14.99) |
αPatients Mean (SD), βFamily members Mean (SD)
Table 3. Comparison of MiL of the participants based on some of their demographic characteristics.
| Variable | Mean (SD) | P-value |
|---|---|---|
| Gender | ||
| Patients with cancer | ||
| Female | 102.5 (18.2) | 0.002 |
| Male | 112.4 (16.1) | |
| Family members | ||
| Female | 126.1 (15.3) | 0.001 |
| Male | 157.4 (15.1) | |
| Occupational status | ||
| Patients with cancer | ||
| Self-employed | 119.2 (16.1) | 0.098 |
| Handworker | 98.5 (14.5) | |
| Governmental staff | 124.4 (13.3) | |
| Housewife | 121.7 (17.4) | |
| Family members | ||
| Self-employed | 118.5 (15.5) | 0.102 |
| Handworker | 111.5 (35) | |
| Governmental staff | 117.7 (18.2) | |
| Housewife | 128.3 (14.1) | |
| Marital status | ||
| Patients with cancer | ||
| Single | 121.2 (17.3) | 0.032 |
| Married | 128.6 (19.2) | |
| Divorced | 124.5 (18.1) | |
| Widowwidower | 119.7 (17.1) | |
| Family members | ||
| Single | 121.5 (18.2) | 0.041 |
| Married | 132.4 (19.5) | |
| Divorced | 126.8 (18.4) | |
| Widowwidower | 108.9 (17.1) | |
| Financial status | ||
| Patients with cancer | ||
| Income more than expense | 142.5 (17.6) | 0.001 |
| Income less than expense | 102.3 (16.5) | |
| Income equal to expense | 114.3 (18.3) | |
| Family members | ||
| Income more than expense | 154.7 (17.4) | 0.001 |
| Income less than expense | 100.3 (17.9) | |
| Income equal to expense | 116.2 (16.62) |
Discussion
Based on a thorough review of existing literature, this study is among the pioneering investigations into meaning in life (MiL) among Iranian cancer patients and their family members. The findings of this meaning comparative study revealed a significant difference in MiL levels between patients and their family members, with family members reporting higher MiL scores. This observation aligns with a study conducted in Turkey, which indicated a loss of MiL in Turkish cancer patients, who often exhibited indecisiveness and diminished motivation to find purpose and meaning.16 Conversely, a study in eastern Pennsylvania reported higher MiL scores among cancer patients.21
It is plausible that cultural and national contexts significantly shape a patient’s experience of MiL when facing cancer. Confronting cancer can challenge an individual’s worldview, prompting questions about previously held beliefs regarding the world’s benevolence, personal deservingness of events, and the extent of control over negative circumstances. Furthermore, cancer patients often seek meaning within their experience, potentially mediating cultural influences on the presence of meaning. This search for meaning aims to either integrate the experience into existing belief systems or revise beliefs to better accommodate the new reality.
Consequently, the findings of this study underscore the importance of existing research in this area.14, 22, 23
The role of family members in cancer caregiving is often demanding, both physically and emotionally, potentially threatening their own sense of MiL. This can directly impact their capacity to manage new responsibilities and adapt to persistent uncertainty. Therefore, both cancer patients and their family members require substantial support from healthcare professionals and various support services to effectively manage their responsibilities while safeguarding their own well-being. Enhancing healthcare professionals’ understanding of the scope, nature, and contributing factors influencing MiL in family members of cancer patients, as well as their unmet needs, is crucial for developing effective, family-centered clinical interventions.24, 25
The present study also identified significant associations between participant demographics and MiL. Gender differences were observed, with women in both patient and family groups reporting lower MiL than men. Marital status also played a role, with married individuals demonstrating the highest MiL levels. Financial status was significantly correlated with MiL, showing a positive trend between increased household income and higher MiL scores. However, no significant association was found between occupational status and MiL. In contrast, Eric’s study found no gender influence on MiL among cancer patients.16 Similarly, a Hungarian study by Skrabski et al. reported a weak correlation between gender and MiL.26 Another recent study by Tomas-Sabado et al. in Barcelona, Spain, also found no significant gender differences in MiL among advanced cancer patients.10 These findings are consistent with previous research suggesting that despite varying coping mechanisms between men and women, gender may not significantly affect the ultimate perception of MiL.27, 28 These discrepancies highlight the need for further research to identify predictors of MiL in cancer patients and their families.
Consistent with our findings, a study by Garland et al. indicated a significant association between the presence of meaning and being married or partnered, a finding supported by substantial literature.29, 30 Similarly, Afrooz et al. reported higher hope levels in married cancer patients, highlighting the role of social support.31 These results collectively suggest that social support is a vital factor in fostering meaning in the lives of cancer patients and their families.
The study revealed that a majority of both patient and family participants reported financial strain, with income levels lower than or equal to living expenses. Financial status significantly impacted MiL, aligning with Fathollahzade et al.’s findings of moderate to high financial distress in Iranian cancer patients, which intensified with decreased income.32 A German study by Fegg et al. also found higher satisfaction and potentially MiL in palliative care patients with sufficient financial resources.33 The cancer experience, from diagnosis to treatment, creates significant financial burdens for patients and families, negatively affecting their MiL. Healthcare system administrators should consider implementing measures to address these financial challenges.
Despite the valuable insights, this study has limitations. The convenience sampling from two university hospitals in specific Iranian provinces may limit the generalizability of findings to all Iranian cancer patients and families. Additionally, potential underreporting of MiL by patients due to social desirability bias cannot be entirely excluded. However, efforts were made to mitigate this through clear explanation of study objectives and debriefing. Despite these limitations, the findings offer valuable insights into cultural variations in MiL perceptions among cancer patients and families.
Future research should explore diverse facets of MiL, its predictors, and strategies for healthcare professionals to better identify and address MiL and its contributing factors in larger, more diverse samples across various regions of Iran and different cultures globally. Longitudinal studies examining MiL across different cancer types and stages (diagnosis, treatment, survivorship, advanced disease) are also recommended.
Conclusion
This meaning comparative study revealed: (a) lower levels of MiL among cancer patients compared to their family members, highlighting the existential challenges patients face in finding meaning and hope amidst their diagnosis; (b) the influence of demographic and disease/treatment characteristics, such as gender, marital status, and financial status, on MiL; and (c) indications of cultural variations in MiL experiences. These findings necessitate specific considerations within the Iranian healthcare system. Enhancements such as providing supplementary insurance for cancer treatments and connecting patients with relevant charities through healthcare administration could be beneficial. Given the critical importance of MiL for the well-being of cancer patients and their families, it should be integrated into personalized care plans aimed at maximizing comfort and quality of life. The results of this study contribute to the growing body of oncology nursing literature and should inform clinical practice and future research in related areas. A comprehensive understanding of MiL empowers healthcare professionals to facilitate patients and families in processing their psychological states, delivering holistic care, and providing targeted counseling referrals to mitigate physical, mental, and emotional health consequences. Furthermore, recognizing the association between MiL and demographic and disease/treatment characteristics necessitates tailored assessment approaches that consider MiL and identify potential sources of meaning for each individual.
Acknowledgments
This study originated from a nursing master’s thesis approved by the IRB of Tabriz School of Nursing and Midwifery and was supported by a grant from the research deputy of Tabriz University of Medical Sciences. The authors express their sincere gratitude to all participating cancer patients, their family members, nurses, physicians, and administrators of Tabriz and Ardebil university hospitals.
Ethical issues
None to be declared.
Conflict of interest
The authors declare no conflict of interest in this study.
Please cite this paper as: Hassankhani H, Soheili A, Hosseinpour I, Eivazi Ziaei J, Nahamin M. A comparative study on the meaning in life of patients with cancer and their family members. J Caring Sci 2017; 6 (4): 325-33. doi:10.15171/jcs.2016.031.
References
[1] Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, et al. Cancer incidence and mortality worldwide: sources, methods and global patterns in GLOBOCAN 2012. Int J Cancer. 2015;136(5):E359-86. [DOI:10.1002/ijc.29210]
[2] Boyle P, Levin B. World Cancer Report 2008. Lyon: IARC Press; 2008.
[3] Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27(17):2758-65. [DOI:10.1200/JCO.2008.20.8983]
[4] Mousavi SM, Harirchi I, Ebrahimi M, Mohagheghi MA, Mousavi-Jarrahi A, Naghavi M. Cancer incidence and mortality in Iran in 2005. Iran J Cancer Prev. 2009;2(1):5-17.
[5] Sadjadi A, Naghavi M, Semnani S, Mousavi SM, Solaimanizadeh L, Sepanlou SG, et al. Cancer occurrence in Iran in 2008, an analysis of population-based cancer registry data. Iran J Public Health. 2013;42(Suppl 1):1-16.
[6] Gill TM, Feinstein AR. A critical appraisal of the quality of quality-of-life measurements. JAMA. 1994;272(8):619-26.
[7] Steger MF. Meaning in life. In: Lopez SJ, Snyder CR, editors. Handbook of positive psychological assessment. Washington, DC: American Psychological Association; 2003. pp. 437-50.
[8] Wong PT. Meaning-centered counseling. In: Corsini RJ, Wedding D, editors. Current psychotherapies. 7th ed. Belmont, CA: Brooks/Cole; 2005. pp. 634-72.
[9] Frankl VE. Man’s search for meaning. Boston: Beacon Press; 1959.
[10] Tomas-Sabado J, de la Vega DM, Villalobos AM, Centeno C, Arantzamendi M. Meaning in life and spiritual well-being in advanced cancer patients: influence of gender and religious beliefs. Support Care Cancer. 2016;24(2):911-8. [DOI:10.1007/s00520-015-2849-9]
[11] Holland JC. Psycho-oncology. New York: Oxford University Press; 1998.
[12] LeMay K, Wilson KG. Meaning in life therapy for patients with advanced cancer. Can J Psychiatry. 2008;53(9):626-34. [DOI:10.1177/070674370805300907]
[13] Breitbart W, Rosenfeld B, Pessin H, Applebaum A, Kulikowski J, Lichtenthal WG. Meaning-centered group psychotherapy for patients with advanced cancer: a pilot randomized controlled trial. Psychooncology. 2015;24(2):158-67. [DOI:10.1002/pon.362]
[14] Baumeister RF. Meanings of life. New York: Guilford Press; 1991.
[15] Frankl VE. The will to meaning: foundations and applications of logotherapy. New York: Meridian; 1988.
[16] Eric E. Meaning of life in cancer patients in Turkey. J Psychosoc Oncol. 2010;28(1):1-15. [DOI:10.1080/07347330903372181]
[17] Janoff-Bulman R. Shattered assumptions: towards a new psychology of trauma. New York: Free Press; 1992.
[18] Pinquart M, Duberstein PR. Associations of meaning in life with psychological well-being and health in old age: a meta-analysis. J Gerontol B Psychol Sci Soc Sci. 2001;56(4):P267-87.
[19] Krause N. Meaning in life and mortality. Gerontologist. 2009;49(3):399-409. [DOI:10.1093/geront/gnp025]
[20] Salmon P, Sephton SE, Lickley LA, رساله دکتری . Meaning in life and psychological adjustment to cancer. University of Oxford; 1996.
[21] Herth K. Fostering hope in terminally-ill people. J Adv Nurs. 1990;15(10):1250-9. [DOI:10.1111/j.1365-2648.1990.tb01628.x]
[22] Reker GT, Peacock EJ, Wong PT. Meaning and purpose in life and well-being: a life-span perspective. J Gerontol. 1987;42(1):44-9.
[23] Zika S, Chamberlain K. On the relation between meaning in life and psychological well-being. Br J Health Psychol. 1992;31(Pt 2):113-23.
[24] Northouse LL. Family members’ experiences with cancer. Behav Med. 1995;21(4):149-56. [DOI:10.1080/08964289.1995.9934675]
[25] Weitzner MA, McMillan SC, Jacobsen PB. Family adaptation to cancer: a review of the literature. Cancer Control. 1999;6(6):578-88. [DOI:10.1177/107327489900600607]
[26] Skrabski A, Kopp MS, Novak M, Rózsa S, Réthelyi J, Bitter I. Meaning in life as a protective factor against suicidal behaviour: a community-based study in Hungary. Eur J Public Health. 2005;15(4):349-53. [DOI:10.1093/eurpub/cki008]
[27] Folkman S, Lazarus RS, Dunkel-Schetter C, DeLongis A, Gruen RJ. Stress processes and depressive mood among bereaved caregivers. J Abnorm Psychol. 1987;96(2):104-13.
[28] Stanton AL, Danoff-Burg S, Cameron CL, Bishop M, Collins CA, Kirk SB, et al. Emotionally expressive coping predicts psychological and physical adjustment to cancer. J Consult Clin Psychol. 2000;68(5):875-82.
[29] Garland SN, Carlson LE, स्पेसमैन A, Patel S, Tamagawa R, Phan T, et al. Meaning-making and spirituality in men with prostate cancer: cross-sectional findings. Integr Cancer Ther. 2013;12(6):476-85. [DOI:10.1177/1534735413485999]
[30] Taylor EJ, Ferrell BR, Grant M, Cheyney L. Managing cancer pain at home: the experiences of patients and their caregivers. Oncol Nurs Forum. 1993;20(6):907-17.
[31] Afrooz GA, Jafari N, Najafi M, Ahmadi F. Hope and quality of life in cancer patients undergoing chemotherapy. Indian J Palliat Care. 2013;19(3):172-6. [DOI:10.4103/0973-1075.121546]
[32] Fathollahzade F, Mohammadi M, Biglarrian A, Ghorbani M, Esmaily H. Financial distress in Iranian cancer patients: a cross-sectional study. Support Care Cancer. 2014;22(10):2721-8. [DOI:10.1007/s00520-014-2290-x]
[33] Fegg MJ, Brandstätter M, Leibrecht KW, Waldminghaus F, Bausewein C, Hauf S, et al. Meaning in life in palliative care patients. J Pain Symptom Manage. 2008;36(5):453-9.
