Journal of Cancer Survivorship

, Volume 9, Issue 1, pp 68–79 | Cite as

The Concerns About Recurrence Questionnaire: validation of a brief measure of fear of cancer recurrence amongst Danish and Australian breast cancer survivors

  • Belinda ThewesEmail author
  • Robert Zachariae
  • Søren Christensen
  • Tine Nielsen
  • Phyllis Butow



Fear of cancer recurrence (FCR) is prevalent amongst survivors, and breast cancer survivors are particularly vulnerable. Currently, there are few well-validated brief measures of FCR and none specific to breast cancer. This manuscript describes the development and initial validation of a new measure of FCR for breast cancer survivors, the Concerns about Recurrence Questionnaire (CARQ), and reports its initial validation in an Australian and Danish population-based sample of breast cancer survivors.


CTT analyses explored scale reliability and validity; Rasch analyses explored model fit statistics, item bias (DIF) and local dependency. Three-item, four-item and five-item versions were considered.


Two hundred eighteen Australian women aged 28–45 years diagnosed with early-stage breast cancer (stages 0–2) and 2001 Danish women diagnosed with breast cancer (stages 1–3) aged 26–70 completed the CARQ. Based on the results of both CTT and IRT analyses, the four-item English version of the scale performed best. Although the CTT analyses suggested that the CARQ-4 was reliable and valid in both samples, Rasch analyses identified item bias relative to age, and local dependence which may be remedied by further scale development.


The CARQ-4 English version is currently one of the most rigorously tested brief scales of FCR available.

Implications for Cancer Survivors

The availability of more valid and reliable brief measures of FCR will help to promote research and screening of FCR amongst cancer survivors.


Cancer Oncology Fear of recurrence Psychological assessment Measurement scale 



B. Thewes was supported by a National Breast Cancer Post-Doctoral Research Fellowship. This study was funded by a Union for International Cancer Control Yamagiwa-Yoshida International Cancer Grant. P. Butow was supported by a NH&MRC Research Fellowship Award. We also wish to thank the Danish Cancer Society for financial support (PP05020) and the Danish Breast cancer Cooperative Group (DBCG) for providing the clinical data for the Danish sample.

Conflict of interest

The authors have no conflicts of interest to declare.


  1. 1.
    Siegel R, DeSantis C, Virgo K, et al. Cancer treatment and survivorship statistics. CA Cancer J Clin. 2012;62(4):220–41.CrossRefPubMedGoogle Scholar
  2. 2.
    Armes J, Crowe M, Colbourne L, et al. Patients’ supportive care needs beyond the end of cancer treatment: a prospective, longitudinal survey. J Clin Oncol. 2009;27(36):6172–9.CrossRefPubMedGoogle Scholar
  3. 3.
    Hodgkinson K, Butow P, Hunt G, et al. The development and evaluation of a measure to assess cancer survivors’ unmet supportive care needs: the CaSUN (Cancer Survivors’ Unmet Needs measure). Psycho-Oncology. 2007;16(9):796–804.CrossRefPubMedGoogle Scholar
  4. 4.
    Thewes B, Boyes A, Girgis A. Fear of cancer recurrence in the first year after diagnosis; results of a registry based study. Quebec: 12th World Congress of International Psycho-Oncology Society (IPOS); 2010.Google Scholar
  5. 5.
    Vickberg SMJ. The concerns about recurrence scale (CARS): a systematic measure of women’s fears about the possibility of breast cancer recurrence. Ann Behav Med. 2003;25(1):16–24.CrossRefPubMedGoogle Scholar
  6. 6.
    Simard S, Thewes B, Humphris G, et al. Fear of cancer recurrence in adult cancer survivors: a systematic review of quantitative studies. J Cancer Survivorship. 2013. doi: 10.1007/s11764-013-0272-z.Google Scholar
  7. 7.
    Thewes B, Butow P, Zachariae B, et al. Fear of cancer recurrence: a systematic literature review of self-report measures. Psycho-Oncology. 2012;21(6):571–87. doi: 10.1002/pon.2070.CrossRefPubMedGoogle Scholar
  8. 8.
    Scientific Advisory Committee of the Medical Outcomes Trust. Assessing health status and quality-of-life instruments: attributes and review criteria. Qual Life Res. 2002;11:193–205.CrossRefGoogle Scholar
  9. 9.
    Lipscomb J, Gotay C, Snyder C. Patient-reported outcomes in cancer: a review of recent research and policy initiatives. CA J Cancer Clin. 2007;57:278–300.CrossRefGoogle Scholar
  10. 10.
    Greenberg DB, Kornblith AB, Herndon JE, et al. Quality of life for adult leukemia survivors treated on clinical trials of cancer and leukemia group B during the period 1971–1988: predictors for later psychologic distress. Cancer. 1997;80(10):1936–44.CrossRefPubMedGoogle Scholar
  11. 11.
    Gotay CC, Pagano IS. Assessment of survivor concerns (ASC): a newly proposed brief questionnaire. Health Qual Life Outcomes. 2007;13(5):15.CrossRefGoogle Scholar
  12. 12.
    Simard S, Savard J. Fear of cancer recurrence inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009;17(3):241–51.CrossRefPubMedGoogle Scholar
  13. 13.
    Thewes B, Butow P, Bell ML, et al. Fear of cancer recurrence in young women with a history of early-stage breast cancer: a cross-sectional study of prevalence and association with health behaviours. Support Care Cancer. 2012;20(11):2651–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Christensen S, Zachariae R, Jensen A, et al. Prevalence and risk of depressive symptoms 3–4 months post-surgery in a nationwide cohort study of Danish women treated for early stage breast-cancer. Breast Cancer Res Treat. 2009;113(2):339–55.CrossRefPubMedGoogle Scholar
  15. 15.
    Easterling DV, Leventhal H. Contributions of concrete cognition to emotion: neutral symptoms as elicitors of worry about cancer. J Appl Psychol. 1989;74(5):787–96.CrossRefPubMedGoogle Scholar
  16. 16.
    Simard S, Savard J. Screening and psychiatric comorbidity of clinical fear of cancer recurrence. Vancouver: 4th Canadian Breast Cancer Research Alliance Reasons for Hope Scientific Conference; 2008.Google Scholar
  17. 17.
    Newman MG, Zuellig AR, Kachin KE, et al. Preliminary reliability and validity of the GAD-Q-IV: a revised self-report diagnostic measure of generalized anxiety disorder. Behav Ther. 2002;33:215–33.CrossRefGoogle Scholar
  18. 18.
    Lovibond SH, Lovibond PF. Manual for the depression anxiety stress scales. 2nd ed. Sydney: Psychology Foundation; 1995.Google Scholar
  19. 19.
    Conradt M, Cavanagh M, Franklin J, et al. Dimensionality of the whitely index: assessment of hypochondriasis in an Australian sample of primary cancer patients. J Psychosom Res. 2006;60:137–43.CrossRefPubMedGoogle Scholar
  20. 20.
    Kincaid JP, Fishburne RP, Rogers RL, Chissom BS. Derivation of new readability formulas (automated readability index, fog count, and flesch reading ease formula) for navy enlisted personnel. Naval Air Station Memphis, TN; 1975.Google Scholar
  21. 21.
    Fischer G, Molenaar I. Rasch models: foundations, recent developments and applications. New York: Springer Verlag; 1995.CrossRefGoogle Scholar
  22. 22.
    Smith EV, Smith RM. Introduction to Rasch measurement. Maple Grove: JAM Press; 2004.Google Scholar
  23. 23.
    Christensen KB, Kreiner S, Mesbah M. The Rasch model for dichotomous items. In: Rasch models in health. London: ISTE Ltd, Wiley; 2013. p. 5–26.Google Scholar
  24. 24.
    Mesbah M, Kreiner S, et al. Rasch models for ordered polytomous items. In: Rasch models in health. London: ISTE Ltd, Wiley; 2013. p. 27–42.CrossRefGoogle Scholar
  25. 25.
    Kreiner S, Nielsen T. Item analysis in DIGRAM 3.04. Part I: Guided tours. Research report 2013/06. Copenhagen 2013.Google Scholar
  26. 26.
    Nielsen T, Kreiner S. Improving items that do not fit the Rasch model: exemplified with the physical functioning scale of the SF-36. Ann Inst Stat Univ Paris Publ Inst Stat’Univ Paris. 2013;57(1–2):91–110.Google Scholar
  27. 27.
    Hamon A, Mesbah M. Questionnaire reliability under the Rasch model. In: Mesbah M, Cole BF, Lee MT, editors. Statistical methods for quality of life studies. Dordrecht: Kluwer Academic Publishers; 2002. p. 155–68.CrossRefGoogle Scholar
  28. 28.
    Andersen EB. A goodness of fit test for the Rasch model. Psychometrika. 1973;38:123–40.CrossRefGoogle Scholar
  29. 29.
    Kreiner S, Christensen KB. Analysis of local dependence and multidimensionality in graphical loglinear Rasch models. Commun Stat Theory Methods. 2004;33(6):1239–76.CrossRefGoogle Scholar
  30. 30.
    Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and powerful approach to multiple testing. J R Stat Soc. 1995;57:289–300.Google Scholar
  31. 31.
    Kreiner S, Christensen KB. Graphical Rasch models. In: Mesbah M, Cole BF, Lee MT, editors. Statistical methods for quality of life studies. Dordrecht: Kluwer Academic Publishers; 2002. p. 187–203.CrossRefGoogle Scholar
  32. 32.
    Kreiner S, Christensen KB. Validity and objectivity in health related summated scales: analysis by graphical loglinear Rasch models. In: von Davuer M, Carstensen C, editors. Multivariate and mixture distribution Rasch models—extensions and applications. New York: Springer Verlag; 2006.Google Scholar
  33. 33.
    Bollen K. Structural equations with latent variables. New York: Wiley; 1989.CrossRefGoogle Scholar
  34. 34.
    Hu L, Bentler P. Cutoff criteria for fit indexes in covariance structure analysis: conventional criteria versus new alternatives. Struct Equ Model. 1999;6:1–55.CrossRefGoogle Scholar
  35. 35.
    Lambert SD, Pallant JF, Boyes AW, et al. A rasch analysis of the hospital anxiety and depression scale (HADS) among cancer survivors. Psychol Assess. 2013. doi: 10.1037/a0031154.Google Scholar
  36. 36.
    Ong A, Bergeman C, Boker S. Resilience comes of age: defining features in later adulthood. J Pers. 2009;77(6):1777–804.PubMedCentralCrossRefPubMedGoogle Scholar
  37. 37.
    Curran D, van Dongen JP, Aaronson NK, et al. Quality of life of early-stage breast cancer patients treated with radical mastectomy or breast-conserving procedures: results of EORTC trial 10801. The European Organization for Research and Treatment of Cancer (EORTC), Breast Cancer Co-operative Group (BCCG). Eur J Cancer. 1998;34(3):307–14.CrossRefPubMedGoogle Scholar
  38. 38.
    Hartl K, Janni W, Kastner R, et al. Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients. Ann Oncol. 2003;14(7):1064–71.CrossRefPubMedGoogle Scholar
  39. 39.
    Mast ME. Survivors of breast cancer: illness uncertainty, positive reappraisal, and emotional distress. Oncol Nurs Forum. 1998;25(3):555–62.PubMedGoogle Scholar
  40. 40.
    Lebel S, Beattie S, Arès I, Bielajew C. Young and worried: age and fear of recurrence in breast cancer survivors. Health Psychol. 2012.Google Scholar
  41. 41.
    de Vaus DA. Analyzing social science data: 50 key problems in data analysis. London: Sage; 2002.Google Scholar
  42. 42.
    Nunnally J, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw Hill; 1994.Google Scholar
  43. 43.
    Traub RE. Reliability for the social sciences: theory and applications. London: Sage; 1994.Google Scholar
  44. 44.
    Loundsbury J, Gibson L, Saudargas R, et al. Scale development. In: The psychology research handbook: a guide for graduate students and research assistants. Thousand Oaks: Sage; 2006.Google Scholar
  45. 45.
    van den Beuken-van Everdingen MHJ, Peters ML, de Rijke JM, et al. Concerns of former breast cancer patients about disease recurrence: a validation and prevalence study. Psycho Oncol. 2008;17(11):1137–45.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Belinda Thewes
    • 1
    Email author
  • Robert Zachariae
    • 2
    • 3
  • Søren Christensen
    • 2
    • 3
  • Tine Nielsen
    • 4
  • Phyllis Butow
    • 1
    • 5
  1. 1.Centre for Medical Psychology and Evidence-Based Decision-Making School of Psychology Transient BuildingUniversity of SydneySydneyAustralia
  2. 2.Unit for Psychooncology and Health Psychology, Department of Psychology and Behavioural SciencesAarhus UniversityAarhusDenmark
  3. 3.Department of OncologyAarhus University HospitalAarhusDenmark
  4. 4.Department of PsychologyUniversity of CopenhagenCopenhagenDenmark
  5. 5.Psycho-Oncology Cooperative Research Group (PoCOG), School of PsychologyUniversity of SydneySydneyAustralia

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