1. Introduction
nxiety is one of cancer’s most common psychological complications that causes a severe crisis [4]. Anxiety is the inevitable result of encountering ideas of existence such as death, freedom, choice, isolation, and meaninglessness [5]. Another psychological consequence of cancer patients is morbid anxiety. The morbid anxiety goes out of its normal range and becomes so severe that it interferes with the ability to function in daily life [10].
One of the components with an essential role in dealing with problems and stress caused by cancer is spiritual health [12]. Spiritual health is considered as one of the crucial dimensions of health in human beings, which provides a harmonious and integrated connection between the internal forces and some characteristics of stability in life, such as peace, a sense of close connection with oneself, God, society, and the environment [13]. Considering the importance of spirituality in reducing the psychological problems of cancer patients, this study aimed to investigate the relationship between spiritual health, existential anxiety, and morbid anxiety in patients with breast cancer.
2. Materials and Methods 
The research method was descriptive-correlation. The statistical population included all patients with breast cancer referred to Imam Reza Oncology and Radiotherapy Center of Mashhad in 2018. According to the statistical population of 400 people, using the Morgan table, the estimated sample size was 195 people selected by purposive sampling from patients referred to Imam Reza Oncology Radiotherapy Center. Data collection tools included Beck Anxiety Inventory, Lawrence & Good Existential Anxiety Inventory, and Paulotzin & Ellison Spiritual Health Inventory. The Beck Anxiety Inventory consists of 21 questions that describe common symptoms of anxiety. The Existence Anxiety Questionnaire has 32 questions based on the existential components of despair and feelings of emptiness. The Spiritual Health Questionnaire consists of 20 questions and has two components: spiritual health and existential health. The eligible patients were provided with the questionnaires for completion. After completion, the questionnaires were collected, and the data were analyzed using Pearson correlation and multivariate regression.
3. Results
Of the total statistical samples, 95.38% were married, 4.61% were single; 19.8% were 30-40 years old, and 32.82% were 40-50 years old, 31.79% were 50-60 years old, and 15.89% were over 60 years old. Also, 9.23% were undergraduate, 62.05% were diploma and postgraduate, 4% were bachelor, and 4.10% were master and doctorate.
Table 1 shows the dimension of spiritual health, the score of 37.96, and the dimension of existential health, 36.14, was obtained.


In total, the average total score of spiritual health is 74.11, which indicates the average level of the spiritual health of patients with breast cancer. Also, among the dimensions of spiritual health, the average scores of both dimensions are at a relative level. With a slight difference, the average spiritual health is higher than existential health. Comparing the mean scores of existential anxiety in breast cancer patients shows that the level of existential anxiety in breast cancer patients is high. Also, the mean scores related to the morbid anxiety of patients with breast cancer show that the morbid anxiety of these patients is moderate.
Table 2 shows a significant correlation between existential anxiety and spiritual health and existential health, while there is no significant relationship between morbid anxiety and spiritual and existential health.


According to t-values and significance level (Table 3), it can be concluded that both spiritual health (Sig.=0.024) and existential health (sig.=0.002) negatively predict existential anxiety.


4. Discussion and Conclusion
This study aimed to investigate the relationship between spiritual health and existential anxiety and morbid anxiety. The results showed that from the dimensions of spiritual health, both spiritual health and existential health have a significant relationship with the existential anxiety of patients with breast cancer. In explaining this finding, it can be said that spirituality affects the way people deal with difficulties and meaning creation and creates a sense of purpose and self-efficacy for people by creating a positive mental atmosphere that causes feelings such as happiness. Moreover, it is hopeful and, as a result, can reduce the anxiety of existence in cancer patients.
In this study, no significant relationship was observed between morbid anxiety and dimensions of spiritual health. Explaining the possible non-confirmation of the finding, it can be stated that severe physical complications due to cancer and high severity of patients’ anxiety may have played a role in this regard. Also, being religious and spiritual can oppositely affect the person. For example, some religious beliefs may negatively affect a person’s health by encouraging them to avoid or discontinue formal treatment, not seeking timely medical care, avoiding effective preventive health measures, and religious misconduct. This result can also be attributed to the influence of intervention factors such as age, level of education, or economic status of breast cancer patients. Research has shown that older people are more anxious than younger people [37]. The results indicate the importance of addressing spirituality among patients with breast cancer and the need to make the necessary plans to improve their level of spirituality.

Ethical Considerations
Compliance with ethical guidelines
This article has been registered with the code 950261902191 in the research committee of the Azad University, Electronic Branch. All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them.

Funding
The study was extracted from the MA thesis of the second author at the Department of Psychology and Humanities, Faculty of Human Sciences, Khatam University, Tehran. 

Authors' contributions
Conceptualization, writing - review, editing, and writing - original draft: Mandana Niknam; Methodology, sampling, data collection, and data analysis: Fatemeh Sadat Hosseini Poorabardeh.

Conflicts of interest
The authors declared no conflict of interests.


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