Fear of cancer recurrence and its predictive factors among Iranian cancer patients
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0973-1075.132632
Source of Support: None, Conflict of Interest: None
Context: Fear of cancer recurrence (FOCR) is one of the most important psychological problems among cancer patients. In extensive review of related literature there were no articles on FOCR among Iranian cancer patients.
Keywords: Cancer, Cancer recurrence, Fear of progress, Fear of recurrence, Iran
Notable progressions in treating different types of cancers occurred in recent years and as a result, the prognosis of many cancers has improved. ,, However, the diagnosis and the treatment of cancer still initiate a lot of stress in cancer patients and their families. ,, Therefore, in many culture, the diagnosis of cancer can be considered equivalent to death and severe disability. 
One of main stress that many cancer patients may experience during the active phases of cancer treatment  or in their survivorship period , is the fear of cancer recurrence (FOCR). FOCR can be defined as a fear or anxiety of cancer recurrence in primary location or its metastasis in other organs.  The result of previous studies showed that even the FOCR may decrease after the active phase of the treatment, but this fear continues in many cancer patients for many years. , In fact, FOCR is one of the most sever distress that many cancer patients may experience during their disease journey. ,
The results of some studies in England,  Australia ,,, and Hong-Kong  showed that cancer patients considered FOCR as one of their most frequent unmet supportive care needs. FOCR can have many negative effects for cancer patients. For example, finding of previous studies showed that FOCR among the cancer patients is associated with decreased quality of life; ,,,, increased physical and psychological problems; ,,, increased stress and depression;  and decreased in satisfaction with the quality of care. 
According to the results of previous researches, Iranian cancer patients have high levels of distress and depression,  decreased quality of life,  and disappointment about the future.  However, in extensive review of related literature, we did not find any studies that investigated the FOCR in Iranian cancer patients or cancer patients in other Middle Eastern countries. Of course, one qualitative study reported that FOCR is one of the most stressful experience for Iranian cancer patients.  On the other hand, assessment of the fear of cancer patients about recurrence of their disease is important for implementation of any supportive care programs. So, the aim of this study was to investigate FOCR and its predictive factors among Iranian cancer patients.
This descriptive-correlational study was conducted at inpatient wards and outpatient clinic of Ghazi Tabatabay hospital affiliated to Tabriz University of Medical Sciences (TUOMS). Ghazi Tabatabay hospital is a main institute for cancer treatment in East Azerbaijan province and three neighbour provinces in north-west of Iran. In order to increase the general ability of findings, sampling was conducted at two oncologist offices too.
The study population included all the cancer patients who were referred to Ghazi Tabatabay hospital for receiving of curative or palliative treatments during the study period. The inclusion criteria: 18 years or above; having definite diagnosis of cancer; be aware about exact diagnosis of cancer for at least 3 months; having no other chronic disease; and has physical and psychological ability to participate in the study. The sample size of 115 cancer patients was determined after pilot study on a 20 cancer patients and the data of 129 cancer patients was collected during the study period.
The instrument used in this study has two parts. The first part is a researcher prepared checklist that investigated some demographic characters of cancer patients. Some disease-related characteristics of participants were obtained from their medical records. The second part was a short form of fear of progression questionnaire.  This questionnaire is a 12-items instrument and was designed based on fear of recurrence questionnaire.  The response to each item is based on five-point Likert scale ranging from 1 (never) to 5 (often). The final score was obtained by collecting of all items' scores and higher score indicate higher FOCR. If 50% of items had 4 or more score, it was considered as a moderate FOCR and if 75% of items had 4 or more score, it was considered as a high FOCR.  So, according to this instruction and the result of the present study the score of 46.5 was selected as a cut of point for high FOCR.
For using the questionnaire, first English questionnaire was translated and back translated by two independent English translators. The face and content validity of translated questionnaire was determined by 15 academic members from TUOMS and some small changes were done according to their comments. The internal consistency of questionnaire was determined by α Cronbach coefficient (0.87) after pilot study on 20 cancer patients.
For data collection the research protocol was approved by Regional Ethics Committee at TUOMS. Then two researchers invited patients who meet the inclusion criteria from Ghazi Tabatabay hospital and private offices to participate in the study. One of the important criteria for these patients was their awareness about the exact cancer diagnosis. For this purpose, the first patients' awareness about their exact diagnosis was asked from their family members, nurses or treating physicians. Then, this awareness was confirmed by a private interview with patients. This method is approved by Regional Ethics Committee. After that, some oral explanation about aims of the study and participants' right was given to all potential participants and informed consent was obtained from all patients who accepted to participate in the study. The questionnaire was given to educated patients for completion in a private place. In low educated or illiterate patients, data was collected using the private interview conducted by researchers. This survey lasted from March to July in 2013. During this period 139 patients were invited to participate in the study and finally the data of 129 patients were collected (participation rate = 93%).
The data analyses were performed using SPSS software (version 16, SPSS Inc., Chicago, IL, USA). Descriptive statistics were calculated for demographic and disease-related variables and FOCR. The Chi-square and independent samples t-test was used for comparison FOCR in two groups; patents with scores lower and higher than determined the cut of point. Logistic regression analyses were conducted determining the predictive factors of FOCR. P < 0.05 was considered statistically significant in this study.
Demographic and disease-related characters in participants
Some demographic and disease-related characters of participants are reported in [Table 1]. According to this table, most of participants were women, married, educated at primary level, housewife and lived with their husband and children. Mean age of participants was 45 years and average time passed since their awareness about exact diagnosis was 24 months.
Response to items of fear of progression questionnaire
Participants' response to each items of fear of progression questionnaire is reported in [Table 2]. According to this table, the most patients' fear was about their family and the future of their children and the lesser fear was about physical symptoms and fear of physical damage because of cancer treatments. Also, it has been identified that 49.6% of participants have high FOCR according to determined cut-off point.
Relationship between demographic and disease-related factor with FOCR
In [Table 3] the relationship of some demographic and disease-related characters of participants was examined with their FOCR in two groups; patents with scores lower and higher than determined cut-off point. According to this table, FOCR was higher in women, illiterate patients, patients who live with their husband and children, breast cancer patients, and patients with experience of radiotherapy.
Predictive factors of FOCR
Predictive factors of FOCR are reported on [Table 4]. According to this table, being female, having breast cancer and having education lower than university are predictive factors of FOCR.
According to extensive review of related literature, this study is the first of its kind that investigated the FOCR and its predictive factors from the viewpoints of cancer patients in Iran or other Middle Eastern countries.
The result of this study showed that about half of the participants reported high levels of FOCR. In fact, an average score of 45 out of 60 showed the high level FOCR in participants. The results of related studies that investigated the FOCR among the cancer patient were inconsistent. For example, some studies in United States, ,, England,  Norway,  and Germany  showed that, although some of the cancer patients have a moderate to high levels of FOCR, but most of the cancer patients have low level of FOCR. On the other hand, some studies results in Spain  and United States  reported high levels of FOCR among the cancer patients.
It seems that type of cancer and time elapsed since diagnosis are two main factors in intensity of FOCR and resulted in obtaining different results in previous studies.  In this regard, results of some previous studies showed that FOCR was decreased by passing time from initial diagnosis to survivorship. , We can conclude that the results of present studies correlated with the results of previous studies. But, it should be noted that about half of participants reported high levels of FOCR. This level of FOCR did not reported in any previous studies. However, one qualitative study in Iran reported that, in spite of high levels of hope for recovery, Iranian cancer patients were worried about recurrence or progression of their disease.  Of course, the present study is the first reported high levels of FOCR quantitatively. It should be noted that there is no any established study aimed at providing supportive care for Iranian cancer patients.  On the other hand, Iranian health care providers and family members of cancer patients avoid from giving information about the cancer to cancer patients. So, many Iranian cancer patients do not have accurate perception about the prognosis of their disease.  It seems that these items may results in high levels of FOCR among the participants.
These results of the present study showed that women, breast cancer patients, and patients without university degree have more FOCR. The results of previous studies about predictors of FOCR are different. For example, results of a study in England showed that age, sex, and educational levels have no any statistical correlation with FOCR in head and neck cancer patients.  On the other hand, results of one study in Germany indicated that breast cancer patients had high level of FOCR and having a child was a main risk factor for FOCR.  Similarly, the results of other study showed that the fear about family and especially about the future of children is one of the most important worries of cancer patients.  Also, the results of one Iranian qualitative study showed that female cancer patients have more worries about their disease.  As evident, these results are consistent with the results of present study. Finally, according to extensive review of relevant literature it can be articulated that the results of previous studies about predictive factors of FOCR is inconsistent and further studies is needed in this regard.
The results of this research can be used for providing psychological programs for Iranian cancer patients or cancer patients in countries with similar cultural context. This research indicates that half of Iranian cancer patients have a high level of FOCR and need psychological interventions. Also, it is cleared that women and low educated patients noticeably have more FOCR and need more attention.
Results of the present study have some limitations that should be considered for its generalization. This study has been conducted in one province of Iran and does not cover cultural and religious diversity in Iranian society. In this study patients with all cancer types entered and the stage of cancer did not determined for them. In addition, in this study we did not compare the inpatient and outpatient patients. It is possible that there were differences between these patients in their FOCR. Also, the number of women was further than men patients. So, we suggested that another studies should be conducted by considering other important factors, such as cancer stage and hospitalization status of patients. Similar studies should be conducted in other culture and religions in the Middle East for increasing the general ability of the results.
This study is the first study investigating the FOCR among Iranian cancer patients. The results showed that Iranian cancer patients have high level of FOCR. In addition the results showed that women, breast cancer patient, and patients with lower level of education have more FOCR. There is immediate need for supportive care program designed for Iranian cancer patients aimed at decreasing their FOCR.
[Table 1], [Table 2], [Table 3], [Table 4]