© Oncology Nursing Society. Unauthorized reproduction, in part or in whole, is strictly prohibited. For permission to photocopy, post online, reprint, adapt, or otherwise reuse any or all content from this article, e-mail email@example.com. To purchase high-quality reprints, email firstname.lastname@example.org.
May 2012, Volume 39, Number 3
Predicting Fear of Breast Cancer Recurrence
and Self-Efficacy in Survivors by Age at Diagnosis
Kim Wagler Ziner, RN, PhD, George W. Sledge Jr., MD, Cynthia J. Bell, RN, PhD,
Shelley Johns, PsyD, ABPP, Kathy D. Miller, MD, and Victoria L. Champion, RN, PhD
Purpose/Objectives: To determine the effect that age at diagnosis has on fear of breast cancer recurrence and to identify the predictors of fear of recurrence using self-efficacy as a mediator.
Design: Cross-sectional survey.
Setting: Two university cancer centers and one cooperative group in the midwestern United States.
Sample: 1,128 long-term survivors.
Methods: Survivors were eligible if they were aged 18–45 years (younger group) or 55–70 years (older group) at cancer diagnosis, had received chemotherapy, and were three to eight years postdiagnosis. Fear of recurrence was compared between younger and older groups. Multiple regression analyses were used to test variables’ prediction of fear of recurrence and breast cancer survivor self-efficacy, as well as breast cancer survivor self-efficacy mediation effects.
Main Research Variables: Fear of recurrence, breast cancer survivor self-efficacy, and age at diagnosis.
Findings: Survivors diagnosed at a younger age had significantly higher fear of recurrence, as well as health, role, womanhood, death, and parenting worries. Perceived risk of recurrence, trait anxiety, and breast cancer reminders explained significant variance in fear of recurrence and breast cancer survivor self-efficacy. Breast cancer survivor self-efficacy partially mediated the effects of variables on fear of recurrence.
Conclusions: The findings suggest that breast cancer survivor self-efficacy may have a protective effect for survivors who are younger at diagnosis and have higher perceived risk of recurrence, higher trait anxiety, and more breast cancer reminders. Oncology nurses already use the skills required to support self-efficacy. Additional research is needed to define and test breast cancer survivor self-efficacy interventions.
Implications for Nursing: Oncology nurses are in a key role to assess fear of recurrence and provide self-efficacy interventions to reduce it in breast cancer survivors. Strategies to efficiently address fear of recurrence to reduce psychological distress in survivorship follow-up care are warranted.
The American Cancer Society ([ACS], 2012) estimated that more than 2.6 million women in the United States are breast cancer survivors. With increasing early detection and more effective treatment, breast cancer survival rates continue to rise, making psychosocial consequences of breast cancer, such as fear of recurrence, a concern for many women (Ferrell, Grant, Funk, Otis-Green, & Garcia, 1998a; Northouse, 1981; Vickberg, 2001; Welch-McCaffrey, Hoffman, Leigh, Loescher, & Meyskens, 1989). For most breast cancer survivors, fear of recurrence is a life-long concern (Vickberg, 2001). The prevalence of fear of recurrence suggests that survivors and oncology professionals need research to describe the construct and its prevalence and then test interventions to help survivors manage this problem.
Several factors may be relevant to the study of fear of recurrence. For instance, past work has identified age at diagnosis as an important factor in psychological symptoms of breast cancer survivors (Hewitt, Greenfield, & Stovall, 2006). Other variables such as anxiety, knowledge of symptoms, and breast cancer reminders also have been identified (Vickberg, 2001). In addition, self-efficacy demonstrates promise as a construct related to a woman’s ability to handle survivorship problems (Bandura, 1997). Self-efficacy specific to breast cancer survivorship is defined as perceived confidence in managing symptoms and concerns related to diagnosis and treatment of breast cancer. Survivorship literature identifies self-efficacy as a mediator of symptom distress (Cunningham, Lockwood, & Cunningham, 1991; Lev, Paul, & Owen, 1999). The purpose of this research was to determine the effect that age at diagnosis has on fear of recurrence and identify the predictors of fear of recurrence using self-efficacy as a mediator.
Fear of recurrence is a distressing problem for the majority of survivors (Bloom, Stewart, Chang, & Banks, 2004; de Haes, Curran, Aaronson, & Fentiman, 2003; Ferrell et al., 1998a; Härtl et al., 2003; Mast, 1998; Northouse, 1981; Welch-McCaffrey et al., 1989). It interferes with quality of life, enjoyment of life, and global sense of well-being (Cimprich, Ronis, & Martinez-Ramos, 2002; Spencer et al., 1999). In addition, a higher fear of recurrence is correlated with syndromes such as post-traumatic stress disorder in long-term survivors (Mehnert, Berg, Henrich, & Herschbach, 2009; Vickberg, 2003). In one study, fear of recurrence was significantly greater than any other concern, including those related to long-term effects of chemotherapy (Spencer et al., 1999).
Historically, fear of recurrence research has focused only on fear of the cancer returning (Ferrell, Dow, Leigh, Ly, & Gulasekaram, 1995; Härtl et al., 2003; Hilton, 1989; Kornblith et al., 2007; Mast, 1998; Northouse, 1981; Spencer et al., 1999). That approach is limited in that survivors’ perceptions about fear of recurrence rarely are unidimensional. For instance, Vickberg (2001) found that one component of fear of recurrence for many women concerned fear about returning to chemotherapy. Some qualitative research has identified additional components of fear of recurrence. For example, survivors report fear of recurrence because they have young children and worry that a recurrence will not allow them to parent as their children grow (Ferrell et al., 1996). As Vickberg (2001, 2003) explored global fear of recurrence and ongoing worries, she found that survivors had concerns about health, womanhood, work, and relationship roles, as well as death. The same view was reported by other researchers (van den Beuken-van Everdingen et al., 2008). Viewing fear of recurrence as a multidimensional construct will allow clinicians and researchers to tailor fear of recurrence interventions.
Age at diagnosis has been identified as an important covariate for fear of recurrence. Kornblith et al. (2007) found that survivors diagnosed at age 55 or younger had a higher fear of recurrence than those diagnosed at age 65 and older, whereas Cimprich et al. (2002) did not find differences in fear of recurrence in those diagnosed when younger than 45, aged 45–65, and older than 65 years. Both studies had fairly small sample sizes. In addition to age at diagnosis, initial treatment may impact fear of recurrence, including type of surgery, use of radiation, and use of tamoxifen or aromatase inhibitors (Vickberg, 2001). Therefore, the current study was designed with distinct age groups and initial treatment was controlled by including those with chemotherapy.
Time since diagnosis is another potential variable related to fear of recurrence. Some studies only assessed survivors one year or less post-treatment (Spencer et al., 1999), whereas others assessed survivors ranging from a few months to a few years post-treatment (Cimprich et al., 2002; Clayton, Mishel, & Belyea, 2006; Connell, Patterson, & Newman, 2006; Härtl et al., 2003; Hilton, 1989; Mast, 1998; Spencer et al., 1999; Vickberg, 2003). Literature describing the relationship between time since diagnosis and fear of recurrence has been hampered by lack of variability in time since diagnosis, an issue that the current study addressed. Women eligible for this study were three to eight years from initial treatment. Therefore, the authors could address the relationship between time since diagnosis and fear of recurrence. Because a commonly accepted survivorship marker is five years postdiagnosis, the authors decided to include a range before and after this marker (e.g., three to eight years) to control for any differences in perception related to length of time since diagnosis.
Several variables that might act as predictors of fear of recurrence were identified in the literature and clinical practice. In this section, the authors will describe those additional variables, including perceived risk of recurrence, knowledge of someone with a recurrence, symptom bother, recurrence signs, trait anxiety, and breast cancer reminders.
Perceived risk of developing cancer has been studied in the context of cancer worry in populations at high risk for cancer (Easterling & Leventhal, 1989; Loescher, 2003). Individuals who had a higher perceived risk of developing cancer reported greater cancer worry and reported more cancer worry in the presence of increased symptoms (Easterling & Leventhal, 1989). In qualitative research, women described knowing someone with a recurrence (including public figures) as a trigger for their own fear of recurrence (Vickberg, 2001).
Little is known about the knowledge survivors have regarding symptoms of recurrence. The presence of breast cancer-related symptoms and non–breast cancer-related symptoms have been found to be associated with thoughts about recurrence (Clayton et al., 2006). Many survivors experience ambiguous symptoms, such as fatigue, and misinterpret these as signs that their cancer has recurred (Lee-Jones, Humphris, Dixon, & Hatcher, 1997). That may lead to behavioral responses such as repeated body checking, persistent requests for tests, and seeking repeated reassurance from healthcare providers during survivorship (Fredette, 1995; Lee-Jones et al., 1997), as well as the tendency to obsess over symptoms (Figueiredo, Fries, & Ingram, 2004; Welch-McCaffrey et al., 1989).
Although trait anxiety has not been found to increase a woman’s risk of developing breast cancer (Aro et al., 2005), it has been associated with emotional and physical distress (Ferrell et al., 1998a; Hewitt, Herdman, & Simone, 2004). In women with early-stage breast cancer, trait anxiety has been associated with persistent distress for at least two years postdiagnosis (Bleiker, Pouwer, van der Ploeg, Leer, & Adér, 2000). Knowledge of the role of trait anxiety in fear of recurrence could help healthcare providers as they plan, support, and guide anxiety-reduction interventions.
Long-term survivors report the highest levels of fear of recurrence during healthcare-related visits, such as mammography appointments and visits to the healthcare team. Those routine follow-up appointments may coincide with their anniversary date of diagnosis, the most intense reminder of breast cancer (Spencer et al., 1999; Vickberg, 2003). Breast cancer survivor self-efficacy has been demonstrated to be significantly lower in women diagnosed at age 45 years and younger compared to women diagnosed at 55 years or older (Champion, Sledge, Ziner, Monahan, & Zho, 2010).
Theories of emotion and self-efficacy are the basis of the theoretical framework that guides this study. Emotion theorists posit fear is an emotional response to stimuli perceived as harmful (Lazarus, 1991; Ohman, 2000). Self-efficacy is the confidence to produce desired effects by one’s own actions (Bandura, 1997). In this study, self-efficacy is defined as one’s confidence in the ability to manage symptoms and emotions related to having breast cancer, including the ability to ask for help, know how and when to report symptoms, and do what is important after breast cancer treatments are completed. Building on the identified antecedent variables and breast cancer survivor self-efficacy, two research questions were proposed: (a) Does fear of recurrence and related subscales differ between survivors diagnosed at younger and older ages, and (b) does breast cancer survivor self-efficacy mediate the relationship between antecedent variables and fear of recurrence?
Design and Sample
This study used a cross-sectional survey design to collect data within a larger breast cancer survivor quality-of-life study. The larger study was designed with a distinct age gap, leaving out women diagnosed from ages 46–54 years, to test differences between women diagnosed with breast cancer at a young age (45 or younger) and women diagnosed at an older age (55–70); this gap was to allow potentially smaller differences to be detected. A theoretical framework proposing relationships among fear of recurrence, as well as research-identified variables, guided data collection and analysis. Surveys were mailed to participants’ homes after they provided written informed consent.
A total of 1,128 survivors were included in the study. Survivors were eligible if they had been diagnosed from age 18–45 years for the younger group or age 55–70 years for the older group. Eligibility included chemotherapy as part of their treatment and being three to eight years from initial diagnosis. A total of 744 younger and 937 older eligible survivors were contacted and 505 (68%) younger and 623 (67%) older survivors agreed to participate (see Table 1).
Women were recruited from three settings: two Midwestern university cancer centers and one cooperative oncology group. Recruitment proceeded according to Health Insurance Portability and Accountability Act of 1996 guidelines after Indiana University-Purdue University Indianapolis institutional review board approval. Current healthcare providers asked eligible survivors if they were willing to be approached by the study staff. If survivors agreed, healthcare providers sent survivors’ contact information to the study staff, who then contacted interested survivors by phone or in person. Written informed consent was obtained.
Several instruments were used to measure variables hypothesized to affect fear of recurrence. All instruments were tested for content validity by five quality-of-life researchers and three clinical breast cancer experts, with both groups assessing the item-Content Validity Index ([item-CVI] as 1, resulting in an excellent modified kappa statistic [k*] of 1). Twelve survivors confirmed face validity.
Demographic variables, including age at diagnosis, were measured by questions asked as part of the cross-sectional survey. Perceived risk of recurrence was measured by one item: “I will have a breast cancer recurrence at some time in my life,” with a five-point Likert-type response scale ranging from 1 (strongly disagree) to 5 (strongly agree). The single item is similar to one previously used to assess perceived risk of developing cancer for those at high risk (Loescher, 2003).
Knowledge of someone with a recurrence included a single dichotomous item asking whether the survivor knew anyone with a breast cancer recurrence. Qualitative research has identified this as a key component of fear of recurrence. The single item was developed for the current study from qualitative literature identifying this concept (Vickberg, 2001).
Knowledge of Recurrence Signs is a scale that was developed based on the American Society of Clinical Oncology’s (2001) common clinical symptoms of recurrence. It includes 11 items: six common clinical symptoms of recurrence and five symptoms not associated with recurrence. The six common clinical symptoms of recurrence were (a) bone pain or tenderness lasting more than two weeks; (b) skin rashes, redness, or swelling on breast(s), scar, or chest area; (c) new lumps or other changes in breast(s); (d) chest pain and shortness of breath; (e) persistent abdominal fullness, discomfort, or pain; and (f) changes in weight, particularly weight loss. The five symptoms not associated with recurrence were fever, frequent colds, flu-like symptoms, persistent hot flashes, and changes in sleep patterns. Participants were asked to indicate whether the item was a sign of breast cancer recurrence (i.e., true or false). Correct responses were summed for a total score, with a higher score indicating greater knowledge. Internal consistency reliability (Kuder-Richardson formula 20) was 0.77.
Ridner’s Symptom Bother Scale has items to measure the presence and bother of common symptoms associated with arm and chest wall sensations on the mastectomy or lumpectomy side, which were extracted from the Lymphedema Symptom Intensity and Distress Scale–Arm (LSID-A) (Ridner & Dietrich, 2010). A modified version of 12 symptoms, including arm feels heavy, hand swollen, arm swollen, chest swollen, arm feels tight, arm feels hard, numbness, breast pains, skin crawls, change sleeping position because of symptom, and related bother, was used for this study (Cronbach alpha = 0.88). The weighted global index of symptom burden in two studies using the full LSID-A scale had a Cronbach alpha of 0.95 (Ridner & Dietrich, 2010).
The Trait Anxiety Inventory, a 20-item trait subscale, measures how anxious people feel in general (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Median test-retest correlations for the trait anxiety inventory ranged from 0.7–0.77. Concurrent validity with other measures of trait anxiety were high, ranging from 0.73–0.85 (Spielberger et al., 1983). In a pretest, post-test design study of 123 breast cancer survivors, the alpha was reported as 0.92 pretest and 0.94 post-test (Fogarty, Curbow, Wingard, McDonnell, & Somerfield, 1999). In the current sample, Cronbach alpha reliability was 0.93.
Eight items based on survivor accounts of triggers of fear of recurrence (Ferrell et al., 1996; Vickberg, 2001) were provided, including (a) breast cancer fundraising events, (b) helping other women with breast cancer through support groups or individuals calls, (c) my annual date of diagnosis, (d) my mammogram, (e) new symptoms I do not understand, (f) hearing of someone I know who has had a recurrence, (g) routine oncologist appointment, and (h) having blood drawn for tests or IV. An additional choice, “other,” allowed survivors to self-identify triggers not on the list. Survivors identified the amount of time in the last month that the reminders caused them to think about breast cancer. The nine-item, Likert-type scale ranged from 1 (not at all) to 5 (all or most of the time), with 0 = not applicable. Responses were summed. For construct validity, Pearson r correlations were used. The Breast Cancer Reminders scale was significantly correlated with the Impact of Events Scale-Revised (IES-r) (r = 0.41, p < 0.001); all IES-r subscales, including avoidance (r = 0.28, p < 0.001), intrusion (r = 0.43, p < 0.001), and hyper-arousal (r = 0.35, p < 0.001); and the fear of recurrence index of the Concerns About Recurrence Scale (CARS) (r = 0.39, p < 0.001) (Ziner, 2008).
The Breast Cancer Survivor Self-Efficacy Scale was developed for the larger study and measured survivors’ confidence in dealing with concerns related to breast cancer after treatment. The scale used a 14-item, five-point Likert-type scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Items included issues such as being able to ask for help when problems arise, dealing with physical symptoms, and emotional issues from having breast cancer. Responses were summed for a total score. Construct validity was supported with a confirmatory structural equation model (Champion et al., 2011). Cronbach alpha reliability was 0.93 in this sample.
Fear of recurrence was measured using CARS (Vickberg, 2003). CARS is a two-part instrument developed for survivors assessing overall fear of recurrence (fear of recurrence index) and worries related to recurrence. Subscales include death worries (2 items), health worries (11 items), role worries (6 items), and womanhood worries (7 items). A fifth subscale, parenting worries (2 items), was added on the advice of younger survivors who reviewed the measures prior to the current study and was approved by Vickberg (personal communication, July 6, 2004). All subscales employed a five-point Likert-type response format ranging from 0 (not at all) to 4 (all or most of the time) (Vickberg, 2003). The internal consistency reliability of the subscales ranged from 0.81–0.93.
SPSS®, version 14, was used for all analyses. Independent sample t tests were used to compare differences in fear of recurrence among younger and older survivors. Multiple linear regression analyses were used to test the association between each variable and fear of recurrence while adjusting for the effects of other variables. The full sample of 1,128 was available for the independent t test; however, because the authors chose not to impute missing data, the SPSS program included a reduced sample of 1,076 within the multiple regression analysis.
A total of 1,128 survivors were included in the analysis, with about 45% being diagnosed at 45 or younger and 55% being diagnosed from age 55–70. A majority was Caucasian (92%), married (75%), had at least some college education (64%), and had a household income of $50,000 or more (62%). All women were treated with chemotherapy and had some type of surgery; 47% had a lumpectomy, 51% had a mastectomy, and about 2% had both.
Research Question 1 tested for differences between the younger and older survivors on the CARS fear of recurrence index and subscales. Overall, younger women experienced more fear and worry than older women. All t values for independent tests were significant and ranged from 7.7–15.4 (see Table 2). Women diagnosed at a younger age had a significantly higher mean fear of recurrence index and higher mean worries for health, role, womanhood, death, and parenting compared to women diagnosed at an older age. The greatest difference was seen with the parenting worries subscale.
Research Question 2 sought to determine the mediation effect of breast cancer survivor self-efficacy on antecedent variables in predicting fear of recurrence. Multiple linear regressions were used to test the relationships of the antecedent variables, breast cancer survivor self-efficacy, and fear of recurrence using the Baron and Kenny (1986) method. If the unstandardized regression coefficients changed once breast cancer survivor self-efficacy was added to the analysis, the methods suggested by Frazier, Tix, and Barron (2004) were used to test for significance of the mediation.
The antecedents first were regressed on fear of recurrence. Variables negatively associated with fear of recurrence included age at diagnosis (p = 0.001), perceived risk of recurrence (p = 0.001), trait anxiety (p = 0.001), and breast cancer reminders (p = 0.001). Antecedents explained 38% of the variance in fear of recurrence (see Table 3). Other predictors were not significant.
As a second step, breast cancer survivor self-efficacy was regressed on the antecedents. While controlling for other predictors in the model, age at diagnosis was nonsignificantly related to breast cancer survivor self-efficacy. Higher perceived risk of recurrence (p = 0.07), knowledge of someone with a recurrence (p = 0.004), symptom bother (p < 0.001), trait anxiety (p < 0.001), and breast cancer reminders (p = 0.014) all were related inversely to breast cancer survivor self-efficacy.
As a third step, fear of recurrence was regressed on the mediating variable breast cancer survivor self-efficacy (see Table 4). Breast cancer survivor self-efficacy explained about 18% (p < 0.001) of the variance in fear of recurrence. Higher breast cancer survivor self-efficacy predicted lower fear of recurrence.
Finally, fear of recurrence was regressed on antecedent variables and breast cancer survivor self-efficacy. Mediation is indicated when the strength of the relationship between the antecedents and outcome variable is reduced when the mediator enters the analysis (Baron & Kenny, 1986). Therefore, fear of recurrence was regressed on antecedents plus breast cancer survivor self-efficacy (see Table 5). About 18% variance was accounted for by antecedents and self-efficacy on fear of recurrence (p = 0.001).
The strength of the relationship among antecedents and fear of recurrence changed significantly when breast cancer survivor self-efficacy was added to the analysis. For each coefficient, a decrease in the regression coefficient once breast cancer survivor self-efficacy was added to the analysis was tested for significance of change (Frazier et al., 2004). The coefficient change was significant (p = 0.05) for age at diagnosis, perceived risk of recurrence, trait anxiety, and breast cancer reminders. Specifically, the standardized regression coefficients became smaller (less strength) for age at diagnosis (–1.9 to –1.8), perceived risk of recurrence (2.46–2.34), trait anxiety (0.13–0.077), and breast cancer reminders (0.215–0.205). Breast cancer survivor self-efficacy is a significant partial mediator of the relationships between fear of recurrence and age at diagnosis, perceived risk of recurrence, trait anxiety, and breast cancer reminders. Breast cancer survivor self-efficacy was significantly related to fear of recurrence with a regression coefficient of –0.183 (p < 0.001), which explained about 3% of the unique variance in fear of recurrence. Higher breast cancer survivor self-efficacy predicted lower fear of recurrence.
The authors first sought to determine whether a difference existed between breast cancer survivors who were diagnosed at age 45 years or younger compared to those diagnosed at 55–70 years in relation to fear of recurrence. While controlling for time since diagnosis and treatment, survivors diagnosed in the younger age group had higher fear of recurrence and related worries than survivors in the older age group, which is consistent with previous research that reported younger age was associated with more troublesome thoughts of recurrence indirectly through the relationship between higher symptom bother and younger age (Clayton et al., 2006). Other researchers have described a relationship between younger age at diagnosis and higher fear of recurrence (Härtl et al., 2003; Hilton, 1989; Mast, 1998; Vickberg, 2003).
The findings suggest women diagnosed at a younger age may be at higher risk for fear of recurrence in general and of specific worries about fear of recurrence. Age group at diagnosis was considered an antecedent variable in the current study and younger age at diagnosis predicted higher fear of recurrence, but not breast cancer survivor self-efficacy. Other antecedent variables, including perceived risk of recurrence, trait anxiety, and breast cancer reminders, predicted fear of recurrence and breast cancer survivor self-efficacy. The relationship of those antecedent variables with fear of recurrence was mediated by breast cancer survivor self-efficacy. Of those variables, anxiety and thoughts of breast cancer have been explored by others. A study by Mehnert et al. (2009) found that anxiety was related to moderate to high levels of fear of recurrence. After breast cancer is diagnosed, anxiety often has been considered a part of psychosocial distress, a quality-of-life domain that includes fear of recurrence (Ferrell et al., 1998a; Hewitt et al., 2004).
Women with more thoughts about breast cancer triggered by breast cancer reminders had higher fear of recurrence. That finding was supported by qualitative results in the literature (Ferrell et al., 1998b; Vickberg, 2001) and research with older survivors (Clayton et al., 2006). Events that trigger fear of recurrence often were associated with healthcare-related activities such as mammograms, clinic visits, and blood work. Being cognizant of those triggers is an important consideration for survivors and healthcare providers.
Three antecedents did not impact fear of recurrence: knowing someone with a recurrence, knowledge of recurrence signs, and symptom bother. However, other qualitative reports by survivors described knowing someone with a recurrence as a trigger for their own fear of recurrence (Vickberg, 2001). Although the current study’s findings indicated that most survivors had a fairly accurate knowledge of recurrence signs, this knowledge was not correlated with fear of recurrence; higher survivors’ knowledge of recurrence signs alone did not seem to reduce fear of recurrence. Finally, symptom bother was not related to fear of recurrence, although the presence of breast cancer-related symptoms and non–breast cancer-related symptoms have been associated with thoughts of recurrence (Clayton et al., 2006). The difference in the current study may have to do with the type of symptoms reported. In this study, symptoms were not related to clinical signs of breast cancer, but instead were clinical signs related to breast cancer treatment complications (e.g., numbness, discomfort).
Survivors with higher breast cancer survivor self-efficacy had lower fear of recurrence. In addition, breast cancer survivor self-efficacy mediated the relationship between younger age at diagnosis, higher perceived risk of recurrence, higher trait anxiety, more breast cancer reminders, and higher fear of recurrence, indicating that breast cancer survivor self-efficacy may have a protective effect. Self-efficacy for coping with cancer (Merluzzi, Nairn, Hegde, Martinez Sanchez, & Dunn, 2001) found that patients with higher cancer self-efficacy during treatment and immediately after experienced higher general quality of life, less anxiety, and a greater sense of well-being.
Although having clearly delineated age at diagnosis groups was beneficial for the comparison of fear of recurrence in younger and older survivors, conclusions cannot be drawn about fear of recurrence in survivors diagnosed from ages 46–54, as these women were not included in the study. The sample primarily included women who were Caucasian and English speaking, so the results may not generalize to non-Caucasian or non-English speaking survivors. Moreover, the study was a cross-sectional survey, which does not allow any conclusions about fear of recurrence over time.
Implications for Nursing
The study’s findings indicate that breast cancer survivor self-efficacy may be an important construct to use in interventions addressing fear of recurrence in breast cancer survivors. Providing breast cancer survivors with the knowledge and skills to deal with the symptoms resulting from breast cancer may help decrease fear of recurrence as well as anxiety and perceived risk of recurrence.
Oncology and family practice nurses can support survivors by validating that fear of recurrence is an ongoing concern for the majority of survivors and that survivors diagnosed at a younger age are at a higher risk for fear of recurrence and worries about health, life roles, womanhood issues, and parenting. Nurses can educate survivors to anticipate common fear of recurrence triggers. For example, the current study’s findings and qualitative reports discuss healthcare provider visits as triggers for higher fear of recurrence. Nurses can tell survivors that experiencing fearful responses to upcoming healthcare provider visits is normal and can collaborate with survivors to develop a plan to reduce any quality-of-life interference these understandable fears might cause.
Oncology nurses already possess and use the skills required to build and sustain self-efficacy. According to Bandura (1997), self-efficacy is accomplished through mastery, vicarious experiences, verbal persuasion, and emotional arousal. Nurses coach their patients with information and skill-building to achieve mastery. Nurses also use verbal persuasion (e.g., “You can do this!”) to help patients manage symptoms and emotions. In addition, nurses provide knowledge of what is normal among patients’ experiences and refer to trusted support networks that provide vicarious experiences. Emotional arousal may be linked to the ability to act; therefore, nurses assess their patients for emotions that can help motivate them to take needed action or for higher emotional responses that may cause patients to avoid actions and thereby identify those patients who need a referral for more extensive intervention. Therefore, once research provides the information on how survivors build breast cancer survivor self-efficacy, nurses will be prepared immediately to translate this information to practice.
Although the results of this research provide possibilities for intervention, additional research is needed. First, interventions must be defined and tested to develop and strengthen breast cancer survivor self-efficacy. Second, researchers must establish how survivors determine their risk of recurrence and how perceived risk of recurrence relates to actual risk of recurrence (e.g., stage at diagnosis), thus identifying interventions to normalize survivors’ perceived risk of recurrence. Finally, breast cancer survivor self-efficacy reduced the effect of younger age at diagnosis on fear of recurrence, so understanding which other variables or combinations of variables share variance with age at diagnosis warrants additional exploration. Identifying one or more variables that influence that relationship could add to how fear of recurrence is managed, particularly in women diagnosed at younger ages.
American Cancer Society. (2012). What are the key statistics about breast cancer? Retrieved from http://www.cancer.org/Cancer/BreastCancer/DetailedGuide/breast-cancer-key-statistics
American Society of Clinical Oncology. (2001). A patient’s guide: Follow-up care for breast cancer. Alexandria, VA: Author.
Aro, A.R., De Koning, H.J., Schreck, M., Henriksson, M., Anttila, A., & Pukkala, E. (2005). Psychological risk factors of incidence of breast cancer: A prospective cohort study in Finland. Psychological Medicine, 35, 1515–1521. http://dx.doi.org/10.1017/s003329/705005313
Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: Worth.
Baron, R.M., & Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173–1182. http://dx.doi.org/10.1037/0022-35126.96.36.1993
Bleiker, E.M., Pouwer, F., van der Ploeg, H.M., Leer, J.W., & Adér, H.J. (2000). Psychological distress two years after diagnosis of breast cancer: Frequency and prediction. Patient Education and Counseling, 40, 209–217. http://dx.doi.org/10.1016/S0738-3991(99)00085-3
Bloom, J.R., Stewart, S.L., Chang, S., & Banks, P.J. (2004). Then and now: Quality of life of young breast cancer survivors. Psycho-Oncology, 13, 147–160. http://dx.doi.org/10.1002/pon.794
Champion, V., Sledge, G., Ziner, K., Monahan, P., & Zho, Q. (March, 2010). Quality of life in younger versus older breast cancer survivors. Paper presented at the European Breast Cancer Conference in Barcelona, Spain.
Champion, V., Ziner, K., Monahan, P., Sledge, G., Cella, D., Smith, L., & Bell, C. (2011). Development and psychometric testing of a breast cancer survivor self-efficacy scale. Manuscript submitted for publication in Health Education Research.
Cimprich, B., Ronis, D., & Martinez-Ramos, G. (2002). Age at diagnosis and quality of life in breast cancer survivors. Cancer Practice, 10, 85–93. http://dx.doi.org/10.1046/j.1523-5394.2002.102006.x
Clayton, M.F., Mishel, M.H., & Belyea, M. (2006). Testing a model of symptoms, communication, uncertainty, and well-being, in older breast cancer survivors. Research in Nursing and Health, 29, 18–39.
Connell, S., Patterson, C., & Newman, B. (2006). Issues and concerns of young Australian women with breast cancer. Supportive Care in Cancer, 14, 419–426. http://dx.doi.org/10.1007/s00520-005-0003-8
Cunningham, A.J., Lockwood, G.A., & Cunningham, J.A. (1991). A relationship between perceived self-efficacy and quality of life in cancer patients. Patient Education and Counseling, 17(1), 71–78.
de Haes, J.C., Curran, D., Aaronson, N.K., & Fentiman, I.S. (2003). Quality of life in breast cancer patients aged over 70 years, participating in the EORTC 10850 randomized clinical trial. European Journal of Cancer Care, 39, 945–951. http://dx.doi.org/10.1016/SO959-8049(03)00149-7
Easterling, D.V., & Leventhal, H. (1989). Contribution of concrete cognition to emotion: Neutral symptoms as elicitors of worry about cancer. Journal of Applied Psychology, 74, 787–796.
Ferrell, B., Grant, M., Funk, B., Otis-Green, S., & Garcia, N. (1998a). Quality of life in breast cancer survivors: Implications for developing support services. Oncology Nursing Forum, 25, 887–895.
Ferrell, B., Grant, M., Funk, B., Otis-Green, S., & Garcia, N. (1998b). Quality of life in breast cancer: Part II: Psychological and spiritual well-being. Cancer Nursing, 21(1), 1–9.
Ferrell, B.R., Dow, K.H., Leigh, S., Ly, J., & Gulasekaram, P. (1995). Quality of life in long-term cancer survivors. Oncology Nursing Forum, 22, 915–922.
Ferrell, B.R., Grant, M., Funk, B., Garcia, N., Otis-Green, S., & Schaffner, M.L. (1996). Quality of life in breast cancer. Cancer Practice, 4, 331–340.
Figueiredo, M., Fries, E., & Ingram, K.M. (2004). The role of disclosure patterns and unsupportive social interactions in the well-being of breast cancer patients. Psycho-Oncology, 13, 96–105.
Fogarty, L.A., Curbow, B.A., Wingard, J.R., McDonnell, K., & Somerfield, M.R. (1999). Can 40 seconds of compassion reduce patient anxiety? Journal of Clinical Oncology, 17, 371–379.
Frazier, P.A., Tix, A.P., & Barron, K.E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51, 115–134. http://dx.doi.org/10.1037/0022-0188.8.131.52
Fredette, S.L. (1995). Breast cancer survivors: Concerns and coping. Cancer Nursing, 18, 35–46.
Härtl, K., Janni, W., Kästner, R., Sommer, H., Strobl, B., Rack, B., & Stauber, M. (2003). Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients. Annals of Oncology, 14, 1064–1071. http://dx.doi.org/10.1093/annonc/mdg289
Hewitt, M., Greenfield, S., & Stovall, E. (2006). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
Hewitt, M., Herdman, R., & Simone, J. (2004). Meeting psychosocial needs of women with breast cancer. Washington, DC: National Academies Press.
Hilton, B.A. (1989). The relationship of uncertainty, control, commitment, and threat of recurrence to coping strategies used by women diagnosed with breast cancer. Journal of Behavioral Medicine, 12(1), 39–54. http://dx.doi.org/10.1007/BF00844748
Kornblith, A.B., Powell, M., Regan, M.M., Bennett, S., Krasner, C., Moy, B., . . . Winer, E. (2007). Long-term psychosocial adjustment of older vs younger survivors of breast and endometrial cancer. Psycho-Oncology, 16, 895–903. http://dx.doi.org/10.1002/pon.1146
Lazarus, R. (1991). Emotion and adaptation. Oxford, England: Oxford University Press.
Lee-Jones, C., Humphris, G., Dixon, R., & Hatcher, M.B. (1997). Fear of cancer recurrence: A literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology, 6, 95–105.
Lev, E.L., Paul, D., & Owen, S.V. (1999). Age, self-efficacy, and change in patients’ adjustment to cancer. Cancer Practice, 7, 170–176.
Loescher, L.J. (2003). Cancer worry in women with hereditary risk factors for breast cancer. Oncology Nursing Forum, 30, 767–772.
Mast, M.E. (1998). Survivors of breast cancer: Illness uncertainty, positive reappraisal, and emotional distress. Oncology Nursing Forum, 25, 555–562.
Mehnert, A., Berg, P., Henrich, G., & Herschbach, P. (2009). Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psycho-Oncology, 18, 1273–1280. http://dx.doi.org/10.1002/pon.1481
Merluzzi, T.V., Nairn, R.C., Hegde, K., Martinez Sanchez, M.A., & Dunn, L. (2001). Self-efficacy for coping with cancer: Revision of the Cancer Behavior Inventory (version 2.0). Psycho-Oncology, 10, 206–217.
Northouse, L.L. (1981). Mastectomy patients and the fear of cancer recurrence. Cancer Nursing, 4, 213–220.
Ohman, A. (2000). Fear and anxiety: Evolutionary, cognitive, and clinical perspectives. In M. Lewis & J.M. Haviland-Jones (Eds.), Handbook of emotions (pp. 573–593). New York, NY: Guilford Press.
Ridner, S.H., & Dietrich, M. (2010). Development of the lymphedema symptoms intensity and distress survey arm. Journal of Clinical Oncology, 28(Suppl.), 15S.
Spencer, S.M., Lehman, J.M., Wynings, C., Arena, P., Carver, C.S., Antoni, M., . . . Love, N. (1999). Concerns about breast cancer and relations to psychosocial well-being in a multiethnic sample of early-stage patients. Health Psychology, 18(2), 159–168.
Spielberger, C., Gorsuch, R., Lushene, R., Vagg, P., & Jacobs, G. (1983). State-Trait Anxiety Inventory, Form Y. Redwood City, CA: MindGarden.
van den Beuken-van Everdingen, M.H., Peters, M.L., de Rijke, J.M., Schouten, H.C., van Kleef, M., & Patijn, J. (2008). Concerns of former breast cancer patients about disease recurrence: A validation and prevalence study. Psycho-Oncology, 17, 1137–1145.
Vickberg, S.M. (2001). Fears about breast cancer recurrence. Cancer Practice, 9(5), 237–243. http://dx.doi.org/10.1046/j.1523-5394.2001.009005237.x
Vickberg, S.M. (2003). The Concerns About Recurrence Scale (CARS): A systematic measure of women’s fears about the possibility of breast cancer recurrence. Annals of Behavioral Medicine, 25(1), 16–24.
Welch-McCaffrey, D., Hoffman, B., Leigh, S.A., Loescher, L.J., & Meyskens, F.L., Jr. (1989). Surviving adult cancer, Part 2: Psychosocial implications. Annals of Internal Medicine, 111, 517–524.
Ziner, K. (2008). Fear of breast cancer recurrence (Doctoral dissertation). Indiana University, Indianapolis. Retrieved from ProQuest database, No. 3297930.
Kim Wagler Ziner, RN, PhD, is an assistant researcher in the School of Nursing and George W. Sledge Jr., MD, is a distinguished professor in the School of Medicine, both at Indiana University in Indianapolis; Cynthia J. Bell, RN, PhD, is a postdoctoral fellow in the School of Nursing at Vanderbilt University in Nashville, TN; Shelley Johns, PsyD, ABPP, is a postdoctoral fellow at the Walther Cancer Foundation in Indianapolis, IN; and Kathy D. Miller, MD, is an associate professor in the School of Medicine and Victoria L. Champion, RN, PhD, is a distinguished professor in the School of Nursing, both at Indiana University. This research was supported by the American Cancer Society Scholarship in Cancer Nursing (DSCN-05-182-01) and grant #RSGPB-04-089-01-PBP (principle investigator: Champion); an Indiana University Mary Margaret Walther Pre-Doctoral Fellowship; and a National Cancer Institute training grant (R25 CA 117865-01A11) (principle investigator: Champion). This study was conducted by the Eastern Cooperative Oncology Group (Robert L. Comis, MD) and supported, in part, by Public Health Service grants (CA21115 and CA37604) and from the National Cancer Institute Division of Cancer Prevention, National Institutes of Health, and the Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not represent the official views of the National Cancer Institute. Ziner can be reached at email@example.com, with copy to editor at ONFEditor@ons.org. (Submitted February 2010. Accepted for publication June 20, 2011.)