| Objective: Fear of cancer recurrence(FCR)has been demonstrated to be one of the most frequently reported and unmet psychological needs among cancer survivors.In this study,we firstly understood the incidence of FCR among survivors of major cancer incidence types in China through quantitative studies,and categorized the level of FCR among cancer survivors by individual to deeply explore the heterogeneity and impact factors among groups;further clarified the formation process of FCR among cancer survivors through qualitative research methods,analyzed each major stage of FCR formation process and its characteristics and explored the risk and protective factors of FCR.The model of FCR in cancer survivors was constructed based on Uncertainty In Illness Theory and Terror Management Theory,and the pathway relationship between FCR and various factors was explored.METHODS: A mixed-methods study Part I: FCR typing and impact factors of cancer survivors based on latent profile analysis This part is a cross-sectional study design,using a proportionally assigned stratified random sampling method,cancer survivors of lung cancer,gastrointestinal cancer,breast cancer and gynecologic tumors who were hospitalized and treated in Cancer Hospital of China Medical University from February 2021 to June 2021 were randomly selected as respondents in the ratio of 1:1:1:1.The survey instruments included: General Information Questionnaire,Illness Uncertainty Scale,Hospital Anxiety and Depression Scale,Perceived Social Support Scale and Fear of Recurrence of Cancer Scale short version.SPSS 24.0 statistical software was used to enter and analyze the data,and SPSS 24.0 software and Mplus 8.3 software were applied to statistically analyze the data,and the method of potential profile analysis was used to typify FCR and explore its impact factors.Part II: A qualitative study of FCR among cancer survivors Using the interpretive phenomenological approach in qualitative research,10 cancer survivors hospitalized at the Cancer Hospital of China Medical University from February 2021 to June 2021(sample size was based on data saturation)were selected for face-to-face semi-structured interviews by purposive sampling combined with a maximum difference sampling strategy according to inclusion and exclusion criteria,and the interviews were transcribed,organized and analyzed by applying Giorgi analysis and with the assistance of Nvivo11 software.Part III: Construction and validation of FCR model for cancer survivors Using a quantitative research method,cancer survivors of lung cancer,gastrointestinal cancer,breast cancer and gynecological tumors who were hospitalized and treated at the Cancer Hospital of China Medical University from July 2021 to October 2021 were randomly selected as respondents according to the ratio of 1:1:1:1 based on stratified random sampling by proportional allocation.The survey instruments included: General Information Questionnaire,Illness Uncertainty Scale(Uncertainty Subscale),Hospital Anxiety and Depression Scale(Anxiety Subscale),Perceived Social Support Scale(Family Support Subscale),Anderson Symptom Assessment Scale(Core Symptom Subscale),Impact of Events Scale-Revised and Fear of Cancer Recurrence Scale Short Version.The FCR model for cancer survivors was constructed based on the theoretical basis and Amos 24.0 was applied to fit,modify,evaluate and test the model,and analyze the correlations and mechanisms of effects among the factors.Results: Part I: FCR typing and factors impacting cancer survivors based on latent profile analysis A total of 400 questionnaires were distributed to study participants who met the inclusion and exclusion criteria in this study.A total of 390 valid questionnaires were returned,with a valid questionnaire return rate of 97.5%.(1)The average age of the 390 cancer survivors surveyed was 54.39±10.22 years,and the distribution of cancer types was 107 cases(27.4%)of lung cancer,93 cases(23.8%)of gastrointestinal cancer,97 cases(24.9%)of breast cancer and 93 cases(23.8%)of gynecological tumors.(2)The mean FCR score of cancer survivors was 16.98±5.35(76.7% of cancer survivors had FCR),about 70% of cancer survivors were likely to have anxiety and depression,the number of people with moderate level of illness uncertainty occupied 89.0% of the survey sample,and more than 90% of cancer survivors felt moderate or high level of social support.(3)Potential profile analysis allowed the classification of cancer survivors FCR into three categories:(1)low FCR-extroverted(n=76);(2)medium FCR-regular(n=233);and(3)high FCR-neurotic(n=81).(4)Univariate analysis: The three categories were statistically different in terms of gender,monthly income,education level,occupational status,primary caregiver,cancer type,cancer stage and length of disease diagnosis(P < 0.05).Among them,low-FCRextroverted cancer survivors were less educated,generally had a shorter time to disease diagnosis,and had a higher proportion of retirees than the other categories.In the highFCR-neurotic cancer survivor category,the proportion of lung cancer was 46.9% which was high compared to the other categories.In addition,cancer survivors in different FCR categories had significant differences in anxiety,depression,disease uncertainty and social support(p < 0.001).(5)Multifactor analysis: Unordered multicategorical logistic regression was constructed,and the results showed that anxiety and social support were common predictors for medium FCR-regular and high FCR-neurotic types(P < 0.05),and a positive association was shown between anxiety level and FCR(OR=1.282;1.378),and social support was negatively association(OR=0.948;0.900).High levels of illness uncertainty were a predictor of high FCR-neuroticism(OR=1.078,p=0.012).The lower the income level the greater the likelihood of occurrence of high FCR-neurotic type(OR=10.653,P=0.023).The probability of occurrence of low FCR-extroverted type was greater in those with junior high school or lower education(OR=0.272;0.229).Part II: A qualitative study of FCR in cancer survivors The 10 respondents included in this study consisted of 4 male and 6 female cancer survivors,including 3 with lung cancer,3 with gastrointestinal cancer,and 2 each with breast cancer and gynecologic tumors;mean age was 51.8 years;treatment modalities were surgery(4/10),chemotherapy(2/10),and surgery and chemotherapy(4/10);and 70%(7/10)of respondents had FCR(≥13).The stages and feelings of cancer survivors in the process of FCR formation were summarized and described,and it was found that FCR formation was mainly divided into five stages,in order:(1)the triggering stage included three themes,such as intrusive thinking,disease symptoms and waiting for examination;(2)the uncertainty stage included three themes,such as illness uncertainty,planning uncertainty and treatment uncertainty;(3)the emotional distress stage was mainly manifested by various negative,such as anxiety,depression,guilt,loneliness,and breakdown;(4)the coping strategy stage includes two themes,namely,confrontation and avoidance;(5)the FCR stage includes two themes,namely,the object of fear and risk and protective factors.Although most cancer survivors develop FCR gradually through these five stages,it should be noted that the five stages of FCR formation are not completely fixed or missing.Part III: Construction and validation of FCR model for cancer survivors A total of 277 valid questionnaires were collected in the study,and the valid questionnaire return rate was 92.3%,which satisfied the sample size requirement of this study.(1)The mean age of cancer survivors was 53.77±10.11 years,and the distribution of cancer types were 73 cases(26.4%)of lung cancer,67 cases(24.2%)of gastrointestinal cancer,75 cases(27.1%)of breast cancer and 62 cases(22.4%)of gynecological tumors.(2)Spearman’s correlation analysis showed that there was a positive correlation between FCR and anxiety,illness uncertainty,disease symptoms and post-traumatic stress symptoms(r=0.284-0.602);there was a negative correlation between family support and FCR,anxiety,illness uncertainty,disease symptoms and post-traumatic stress symptoms(r=-0.230-0.582).(3)Harman one-way test could extract four common factors,and the variance explained by the first factor was 43.558%,which was less than the critical criterion of 50%,thus there was no significant common method bias in this study.(4)The factor loading paths of all latent variables in this study reached significance(p < 0.001),and the standard loading coefficients of most of the significant variables were above 0.70,and the values of Average Variance Extracted(AVE)ranged from 0.529 to 0.814,and the CR values range from 0.765 to 0.929,indicating excellent convergent validity of the scale data.The AVE square root values of each factor were greater than their correlation coefficient values with other factors,thus indicating good discriminant validity of the study scale data.(5)The results of the path coefficients of the FCR model for cancer survivors:(1)family support status of cancer survivors significantly and negatively predicted their illness uncertainty(β=-0.24,P=0.004)and anxiety(β=-0.37,P<0.001);(2)disease symptoms of cancer survivors significantly and positively predicted their illness uncertainty(β=0.18,P=0.011);and(3)post-traumatic stress symptoms of cancer survivors significantly and positively predicted their illness uncertainty(β=0.38,P<0.001),anxiety(β=0.30,P<0.001)and recurrence.post-traumatic stress symptoms of cancer survivors significantly and positively predicted their disease uncertainty(β=0.38,P<0.001),anxiety(β=0.30,P<0.001)and FCR(β=0.32,P<0.001);(4)illness uncertainty significantly and positively predicted anxiety(β=0.27,P<0.001)and FCR(β=0.37,P <0.001);(5)anxiety could significantly and positively predict FCR(β=0.24,P=0.008).(6)The mediating effects of the model were tested:(1)illness uncertainty and anxiety played multiple mediating roles between family support,disease symptoms and posttraumatic stress symptoms and FCR;(2)there were indirect effects between family support,disease symptoms and post-traumatic stress symptoms and FCR;(3)there were also direct effects between post-traumatic stress symptoms and FCR.(7)Fit evaluation of the model: the chi-square degrees of freedom ratio was 1.073,CN=258.576>200,RMSEA=0.016<0.05,GFI,AGFI,NFI,IFI,CFI and TLI were all greater than 0.90,representing that all evaluation indexes of this study met the requirements of structural equation model fitness.Conclusion:(1)The incidence of FCR among cancer survivors in China is high,and clinical health care professionals should pay sufficient attention to it.(2)The analysis of potential profiles revealed obvious categorical characteristics of cancer survivor FCR,suggesting that health care professionals should adopt targeted interventions according to the characteristics of different categories of cancer survivors in the clinical practice process.(3)Investigation of general demographic information(education,monthly income,work status and cancer stage)of cancer survivors may help identify patients at risk of recurrence fear,while psychosocial factors(anxiety,disease uncertainty and social support)of cancer survivors may serve as intervention directions to mitigate or avoid the occurrence of recurrence fear.(4)The qualitative study revealed five stages of FCR formation: triggering stage,uncertainty stage,emotional distress stage,coping strategy stage,and FCR stage,respectively.Each stage has its own characteristics,and formulating or constructing corresponding intervention strategies according to the characteristics of different stages is an important direction for future research.(5)Family support,disease symptoms and post-traumatic stress symptoms in cancer survivors can have between or/and indirect effects on FCR through disease uncertainty and anxiety. |
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