This leads to unwanted consequences, such as the body being unable to repair and recover

itself, or fight off external infection so that it will have an impact on the aggressive growth of
cancer (Bowen et al., 2021). In addition, stress on untreated cancer patients can cause long-
term weakening of numerous physiological systems via hormone dysregulation and physical
damage to the nervous system which carries a high risk of physical illness (Chiriac et al., 2018)
(Bowen et al., 2021; Chiriac et al., 2018)

(Eckerling et al., 2021)

Stress management strategies

(Edwards, 2019) (Kalroozi et al., 2022; Zari Moin et al., 2022)

Breast cancer is primary cancer in women and the second (11.6%) or 2089 million cases
after lung cancer (11.6%) or 2094 million cases of all cancers and is the leading cause of death in
women in the world (Bray et al, 2018). Thus, based on the Indonesia Basic Health Survey, from
2013 to 2018, new cancer cases increase from an average of 1.4 to 1.8 per one thousand
population (Kementerian Kesehatan, 2018). Breast cancer can trigger several physical and
psychological changes, such as depression, anger, spiritual crisis, and anxiety (Carlson et al,
2015) as a result of the disease process and treatment (Chan, 2010; Carlson et al, 2012;
Arunachalam et al, 2011). Anxiety is considered the most common and terrible psychological
symptom reported in all women with breast cancer in the world (Kim et al., 2019). It was
recorded that 32.2% of patients experienced anxiety symptoms (Tsaras et al, 2018).
Anxiety can be experienced from the time of diagnosis until undergoing treatment
procedures such as chemotherapy (Pandey et al, 2006). This anxiety is followed by the release
of cortisol and noradrenaline as the body's response to the stress experienced (Chrousos,
2009) and confirmed by the findings of other studies showing that cancer patients have
higher cortisol levels (Chang & Lin, 2017). This leads to unwanted consequences, such as the
body being unable to repair and recover itself, or fight off external infection can cause an
impact on the aggressive growth of cancer, long-term weakening of numerous physiological
systems via hormone dysregulation and physical damage (Bowen et al., 2021; Chiriac et al.,
2018). Therefore, stress in cancer patients must be treated immediately so as not to exacerbate
the disease and the immune system.
The National Cancer Institute (NCI) explained that there are several ways to deal with stress
in cancer patients, such as deep breathing relaxation techniques, stress management
strategies, or psychosocial care (Eckerling et al., 2021). However, Edwards (2019) theorized that
stress is a psychological disorder, it would be better to treat it with a spiritual approach.
Spiritual healing has been reported as the most common complementary therapy used by
patients with cancer to overcome anxiety (Carlson & King, 2012). According to the National
Consensus Project for Quality Palliative (2018), setting quality standards for quality palliative
care, one of which is aspects of spiritual care and religion. It has been reported in several
studies that the majority of cancer patients (84%) use their spiritual or religious beliefs and
practices to cope with their illness. In addition, previous studies also provide evidence that
nearly 85% to 90% of cancer patients report that for cancer patients, spirituality is critical in
helping to overcome their life problems (Gall et al, 2009).
The Indonesian people are sociologically religious that it has become something taken
for granted that prayer is essential for healing, even for solving all life problems. Even in
Islamic literature, it is stated that prayer is the heart of worship. Prayer is the weapon of
the believers. In addition, spirituality can be a coping mechanism for a patient to feel
connected to God, believe in Him, need social support, and find meaning and purpose in
life (Arafat et al, 2018). It is consistent with the study of Dossey (2000), an internist who
conducted extensive research on the effects of prayer on the healing of patients who showed
that prayer and spirituality have as much power as medicine and surgery. This characteristic of
spirituality is a better adjustment to patients' problems, including cancer. Although spiritual
therapy is beneficial in dealing with anxiety and increasing the spiritual well-being of breast
cancer patients (Breitbart, 2015), spiritual therapy using the SEFT approach to reduce anxiety in
breast cancer patients has never been done.
Several studies have alluded to the Spiritual Emotional Freedom Technique but its approach
is on sleep quality, while research has used the spiritual issues via psychological approaches in
reducing anxiety, but this has only been proven by a questionnaire (Kalroozi et al., 2022; Zari
Moin et al., 2022). Apart from that, there is another study with the Prayer on Spiritual Distress
technique where the approach is almost the same (Miranda et al., 2020), but this is a limitation
in terms of technique which is only seen from the patient's prayer aspect or the technique
cannot be proven. Research using the SEFT technique will greatly benefit, especially in
overcoming anxiety in breast cancer patients who have undergone chemotherapy treatment
because this therapy is a complement to other spiritual therapies by combining Spiritual power
and Energy Psychology which is able to generate hope, confidence and be able to solve
psychological problems and physical experience of a person. However, this therapy is mostly
performed on breast cancer patients who experience pain after chemotherapy and no one has
studied their anxiety in depth. Therefore, this study examined the effect of SEFT therapy on
levels of anxiety and cortisol in patients with breast cancer.