By Author
  By Title
  By Keywords

February 2023, Volume 73, Issue 2

Research Article

Patient and illness factors influencing fear of recurrence in breast cancer women

Authors: Lilik Supriati  ( Department of Nursing, Airlangga University, Surabaya, Indonesia. )
I Ketut Sudiana  ( Department of Nursing, Airlangga University, Surabaya, Indonesia. )
Hanik Endang Nihayati  ( Department of Nursing, Airlangga University, Surabaya, Indonesia. )
Ahsan.  ( Department of Health Science, Brawijaya University, Malang, Indonesia. )
Muhammad Rodli  ( Department of Anesthesiology and Intensive Care, Brawijaya University, Malang, Indonesia )
Rinik Eko Kapti  ( Department of Nursing, Brawijaya University, Malang, Indonesia. )


Objective: To analyse the factors influencing the fear of recurrence in breast cancer, including age, spirituality, length of illness, stage of cancer and the cycles of chemotherapy.


Method: The cross-sectional observational study was conducted from November 2021 to February 2022 at Dr Soepraoen Army Hospital and Baptis Hospital, East Java, Indonesia, and comprised breast cancer patients who had received at least one cycle of chemotherapy. Data was collected using the modified Spiritual Transcendence Scale questionnaire as well as from the patient’s medical record. Data were analysed using univariate and linear regression.


Results: There were 135 subjects with a mean age of 47.14±6.36 years (range: 27-60 years). The largest group comprised patients with stage III disease 61(45.2%). Variables affecting the fear of recurrence was length of illness (p=0,007) and spirituality (p=0,001).


Conclusion: Patients who had better spirituality value had lower fear of recurrence.


Keywords: Spirituality, Fear, Breast neoplasms, Medical records. (JPMA 73: S-26 [Suppl. 2]; 2023)





Cancer is the leading cause of death worldwide, accounting for 7.6 million deaths, or about 13% of the total deaths in 2008.1 Globally, the burden of cancer continues to increase, with an expected 19.3 million new cancer cases by 2025.2 The continuing improvement of cancer treatments has led to an increasing number of cancer survivors.3 The 5-year survival rate has risen from 79% to 88% over the past 30 years.4 Advances in medical care and active participation in therapy have made the breast cancer  survival rate relatively higher than the other types of cancer.3-5 In Indonesia, breast cancer accounts for the majority of cancer cases treated in hospitals, and is often detected in an advanced stage.6

Breast cancer is a chronic disease that is full of stress and has implications on many aspects of the patient’s life.7 The death rate from cancer is a stressor that is often feared by patients in addition to the therapy being undertaken.8,9 Facing cancer with a variety of treatment and therapy processes, life-threatening conditions, an uncertain prognosis of cancer, and unpredictability about managing life in the future are the main causes of uncertainty that triggers the fear of recurrence in breast cancer patients.8-10

The fear of recurrence is a worry or concern relating to the possibility that cancer will come back or progress, its relation to the reality of the severity, and the threat of cancer.11 This fear has been shown to be common across all cancer types and persists throughout the survival trajectory, remaining elevated even 6 years post-diagnosis.4 Fear of recurrence is one of the most prevalent psychological burdens experienced by cancer patients and survivors, with previous researches reporting prevalence rates of  the fear of recurrence ranging between 33% and 97%.9 Fear of cancer recurrence is one of the most serious stressors that persistently undermines cancer survivors’ wellbeing.12 Excessive fear of recurrence is associated with reduced quality of life, psychological maladjustment, impaired functioning, interpersonal difficulties and decreased mental health.3-13 It still remains one of the top concerns having negative impacts on patients.8-14

Many factors are associated with the fear of recurrence, including patient, treatment-related characteristics, illness factors or cancer-related and social factors.3-14 The characteristics of patients in determining the fear of recurrence remains inconclusive. Results of multivariate analysis in previous researches suggest such a fear to have a minor role.9-13

Spirituality influences the assessment of various aspects of general health, and refers to the feeling of connectedness to a transcendental entity. It gives life a meaning, and has a stronger impact in the context of illness, but is still inconsistent.15 Illness factors comprise length of illness, cancer stage and cycles of chemotherapy instituted. This factor is postulated to contribute to the formulation of illness representation which determines the patient’s emotional response, but it is a very individual judgement.8

The current study was planned to analyse patients and illness factors affecting the fear of recurrence in breast cancer patients.


Patients and methods


The cross-sectional observational study was conducted from November 2021 to February 2022 at Dr Soepraoen Army Hospital and Baptis Hospital, East Java, Indonesia. After approval from the ethics review board of the Faculty of Nursing, Airlangga University, the sample size was calculated using the rule of thumbs formula.16 The sample was raised using purposive sampling technique.

Those included were female breast cancer patients aged 26-60 years who had received at least one cycle of chemotherapy.  Informed consent was obtained from each of the prospective subject, and those who did not want to participate were excluded.

The research process began with licensing and obtaining clearance from respective administrations regarding compliance with the strict coronavirus disease-2019 (COVID-19) protocol. Data was collected offline by providing a self-assessment questionnaire which was filled out by the subjects themselves.

The demographic section had questions regarding the level of education, occupation, marital status and ownership of health insurance. Variables on spirituality was assessed using a modified Spiritual Transcendence Scale (STS) questionnaire.17 The 9-item scale is scored on a 4-point Likert scale ranging from 1 = strongly disagree to 4 = strongly agree. Validity of the questionnaire was tested on a group of 30 breast cancer women with characteristics similar to those of the study subjects. The reliability score was 0.812, indicating consistency for measuring spirituality.

Data related to cancer stage and cycles of chemotherapy a patient had undergone was retrieved from the medical records. Data was analysed using univariate and multivariate linear regression. Analysis of variance (ANOVA) was used as appropriate. P≤0.05 was considered statistically significant.




There were 135 subjects with a mean age of 47.14±6.36 years (range: 27-60 years). The largest group comprised patients with stage III disease 61(45.2%). The average fear of recurrence was 18.30±4.38, indicating a moderate level (Table 1).



Variables affecting the fear of recurrence was length of illness (p=0,007) and spirituality (p=0,001) (Table 2). Multivariate analysis also confirmed these findings (Table 3).






The study found that the length of illness and spirituality were significant influencing factors. There have been many studies suggesting that spirituality was an additional key factor that has a positive effect on those suffering from diseases, and facilitates easier coping.15-17 Qualitative reports have suggested that breast cancer is sometimes associated with positive spiritual experiences, and survivors rely on spiritual beliefs to cope with their stress.18

Almost all diseases lead to suffering, but not all suffering is caused by diseases. This can encourage some patients to think about the meaning of life. Chronic diseases, such as cancer, can encourage a person to take that path. Changes in the assessment of spiritual attachment play a very important role in patients’ interpretation of the cancer they are experiencing.19 Most patients the current study said they accepted the disease and tried to be grateful to it because they were able to better respect other people, and wanted to have a better life purpose. This is in tune with other studies.1-20

The current study showed there was significant relationship between spirituality and the fear of recurrence with sufficient strength of correlation. This is in accordance with a study done in Iran.21 Also, there was a significant relationship between the length of illness and the fear of recurrence. This is in line with earlier findings.13 Perception of illness is an important factor related to coping patterns and medication adherence. The longer the illness, the patient tends to be more able to accept and is able to adapt to the therapy being undertaken so that the fear may decrease.8

The illness trajectory phase in cancer from the diagnosis and treatment phase has different emotional and distress journeys and different support needs. There are three periods of cancer patients; namely, re-entry, early survivorship and long-term survivorship. The re-entry period is the transition period from a cancer patient to someone with a history of cancer, which is characterised by a period of several weeks to one year of undergoing treatment. In early survivorship, the initial survival period extends to approximately five years post-diagnosis, as the acute treatment-related, physical morbidity has subsided for most survivors by this time. Long-term survival means more than five years post-diagnosis.21 Most of the respondents in the current study were in the early survivorship phase. Another study also  showed  that during the period of illness between 1 and 5 years, breast cancer patients would experience a lot of fear of recurrence.22 The fear recurrence was high in the subjects and it was in line with studies done in China and Denmark.5

The current study has limitations, like a small sample that was insufficient to capture the real situation. Also, the study ignored treatments that the patients had already received, such as mastectomy and radiotherapy, which can affect the fear of recurrence. Further, the study used purposive sampling technique which was adjusted to fulfil the study objectives. As such, not all patients were covered. Finally, the study did not pay attention to other refractive factors, such as the type of chemotherapy drug received and other co-morbidities.




Of the two factors influencing the fear of recurrence, spirituality was the more critical one, determining positive coping to reduce the fear of recurrence. The higher the spirituality, the lower was the fear of recurrence. Therefore, it is necessary to provide nursing care that focuses on improving the spiritual aspect of the patient, such as providing motivation to always think positively, have good self-acceptance, be grateful and be more resigned to fate.


Acknowledgment: We are grateful to the Nursing Faculty of Universitas Airlangga for its valuable contribution, and to the panel of experts from the Oncology Surgery Department, Sidho Hantoko, MD, The oncologist At Army Hospital Soepraoen Malang City for their contribution to the research.


Disclaimer: The study was presented at an international nursing conference held by the Faculty of Nursing, Universitas Airlangga, in April, 2022.


Conflict of Interest: None.


Source of Funding: None.




1.       Gopalan MR, Karunakaran V, Prabhakaran A, Jayakumar KL. Prevalence of psychiatric morbidity among cancer patients - hospital-based, cross-sectional survey. Indian J Psychiatry 2016;58:275-80. doi: 10.4103/0019-5545.191995.

2.      Chaar EA, Hallit S, Hajj A, Aaraj R, Kattan J, Jabbour H, et al. Evaluating the impact of spirituality on the quality of life, anxiety, and depression among patients with cancer: an observational transversal study. Support Care Cancer 2018;26:2581-90. doi: 10.1007/s00520-018-4089-1.

3.      Starreveld DEJ, Markovitz SE, van Breukelen G, Peters ML. The course of fear of cancer recurrence: Different patterns by age in breast cancer survivors. Psychooncology 2018;27:295-301. doi: 10.1002/pon.4505.

4.      Maheu C, Hébert M, Louli J, Yao TR, Lambert S, Cooke A, et al. Revision of the fear of cancer recurrence cognitive and emotional model by Lee-Jones et al with women with breast cancer. Cancer Rep 2019;2:e1172. doi: 10.1002/cnr2.1172.

5.      Götze H, Taubenheim S, Dietz A, Lordick F, Mehnert-Theuerkauf A. Fear of cancer recurrence across the survivorship trajectory: Results from a survey of adult long-term cancer survivors. Psychooncology 2019;28:2033-41. doi: 10.1002/pon.5188

6.      Indonesian Ministry of Health. Guide National Program for the Prevention and Early Detection of Cancer: Cervical Cancer and Breast Cancer. Jakarta, Indonesian: Indonesian Ministry of Health; 2015.

7.      Lee KL, Janz NK, Zikmund-Fisher BJ, Jagsi R, Wallner LP, Kurian AW, et al. What Factors Influence Women’s Perceptions of their Systemic Recurrence Risk after Breast Cancer Treatment? Med Decis Making 2018;38:95-106. doi: 10.1177/0272989X17724441.

8.      Lan M, Zhang L, Zhang Y, Yan J. The relationship among illness perception, coping and functional exercise adherence in Chinese breast cancer survivors. J Adv Nurs 2019;75:75-84. doi: 10.1111/ jan.13832.

9.      Niu L, Liang Y, Niu M. Factors influencing fear of cancer recurrence in patients with breast cancer: Evidence from a survey in Yancheng, China. J Obstet Gynaecol Res 2019;45:1319-27. doi: 10.1111/jog. 13978.

10.    Klungrit S, Thanasilp S, Jitpanya C. Supportive care needs: An aspect of Thai women with breast cancer undergoing chemotherapy. Eur J Oncol Nurs 2019;41:82-7. doi: 10.1016/j.ejon.2019.05.008.

11.    Brédart A, Merdy O, Sigal-Zafrani B, Fiszer C, Dolbeault S, Hardouin JB. Identifying trajectory clusters in breast cancer survivors’ supportive care needs, psychosocial difficulties, and resources from the completion of primary treatment to 8 months later. Support Care Cancer 2016;24:357-66. doi: 10.1007/s00520-015-2799-1.

12.    Xu W, Wang J, Schoebi D. The role of daily couple communication in the relationship between illness representation and fear of cancer recurrence in breast cancer survivors and their spouses. Psychooncology 2019;28:1301-7. doi: 10.1002/pon.5082.

13.    Ng DWL, Kwong A, Suen D, Chan M, Or A, Ng SS, et al. Fear of cancer recurrence among Chinese cancer survivors: Prevalence and associations with metacognition and neuroticism. Psychooncology 2019;28:1243-51. doi: 10.1002/pon.5073.

14.    Shim EJ, Jeong D, Lee SB, Min YH. Trajectory of fear of cancer recurrence and beliefs and rates of medication adherence in patients with breast cancer. Psychooncology 2020;29:1835-41. doi: 10.1002/pon.5497.

15.    Koral L, Cirak Y. The relationships between fear of cancer recurrence, spiritual well-being and psychological resilience in non-metastatic breast cancer survivors during the COVID-19 outbreak. Psychooncology 2021;30:1765-72. doi: 10.1002/pon.5727.

16.    van Belle G, Millard SP. Sample Size: Rule of Thumb. In: STRUTS: Statistical Rules of Thumb. Seattle, WA: University of Washington, 1998; pp 3. [Online] 1998 [Cited 2022 September 20]. Available from URL:

17.    Kang D, Kim IR, Choi EK, Yoon JH, Lee SK, Lee JE, et al. Who are happy survivors? Physical, psychosocial, and spiritual factors associated with happiness of breast cancer survivors during the transition from cancer patient to survivor. Psychooncology 2017;26:1922-8. doi: 10.1002/pon.4408.

18.    Hulett JM, Armer JM, Leary E, Stewart BR, McDaniel R, Smith K, et al. Religiousness, Spirituality, and Salivary Cortisol in Breast Cancer Survivorship: A Pilot Study. Cancer Nurs 2018;41:166-75. doi: 10.1097/NCC.0000000000000471.

19.    Martino ML, Freda MF. Meaning-Making Process Related to Temporality During Breast Cancer Traumatic Experience: The Clinical Use of Narrative to Promote a New Continuity of Life. Eur J Psychol 2016;12:622-34. doi: 10.5964/ejop.v12i4.1150.

20.    Park CL, Waddington E, Abraham R. Different dimensions of religiousness/spirituality are associated with health behaviors in breast cancer survivors. Psychooncology 2018;27:2466-72. doi: 10.1002/pon.4852

21.    Hajian-Tilaki E, Hajian-Tilaki K, Moslemi D, Godazandeh G, Firouzbakht M. Association of social support, spirituality with psychological factorsin Iranian breast cancersurvivors: An evidence from a cross-sectional study. Nurs Open 2022;9:1173-80. doi: 10.1002/nop2.1158.

22.    Martínez Arroyo O, AndreuVaílloY, Martínez López P, Galdón Garrido MJ. Emotional distress and unmetsupportive care needsin survivors of breast cancer beyond the end of primary treatment. Support Care Cancer 2019;27:1049-57. doi: 10.1007/s00520-018-4394-8.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: