Journal of Cancer Survivorship

, Volume 10, Issue 4, pp 663–673 | Cite as

Fear of cancer recurrence: a theoretical review and novel cognitive processing formulation

  • Joanna E Fardell
  • Belinda Thewes
  • Jane Turner
  • Jemma Gilchrist
  • Louise Sharpe
  • Allan ‘Ben’ Smith
  • Afaf Girgis
  • Phyllis ButowEmail author



Fear of cancer recurrence (FCR) is prevalent among survivors. However, a comprehensive and universally accepted theoretical framework of FCR to guide intervention is lacking. This paper reviews theoretical frameworks previously used to explain FCR and describes the formulation of a novel theoretical framework for FCR.


A systematic review of the literature was undertaken to identify conceptual frameworks or theories applied to FCR. MEDLINE, PubMED, CINAHL, AMED, PsycINFO and Web of Science were searched. Identified conceptual frameworks were reviewed for strength of evidence supporting their validity.


Of 558 papers initially identified, 16 made reference to six different conceptual frameworks relating to FCR. The most comprehensive and evidence-based theoretical approach is the Common Sense Model (CSM). Other approaches have limited evidence supporting their application to FCR. Two theoretical approaches developed in the context of emotional disorders that appear to be highly relevant to FCR: the Self-Regulatory Executive Function (S-REF) model and Relational Frame Theory were combined with the CSM to produce a novel cognitive processing account of FCR.


Few conceptual frameworks have been used consistently to guide FCR research, and not all frameworks are empirically well supported, suggesting that further discussion regarding the conceptualisation of FCR is needed. The novel theoretical framework for FCR presented highlights the multidimensional nature of FCR and the importance of cognitive processing and metacognitions in the development and maintenance of FCR.

Implications for Cancer Survivors

The novel theoretical formulation of FCR outlined here provides a much-needed comprehensive framework to further investigate and address FCR in cancer survivors.


Fear of cancer recurrence Cancer Oncology Survivorship Metacognitive Therapy Acceptance and Commitment Therapy 



The work presented in this paper was co-funded by beyondblue, National Breast Cancer Foundation and Cancer Australia (CAPdCCRS 1022584).

Compliance with ethical standards


This review was co-funded by Cancer Australia, beyondblue and National Breast Cancer Foundation (grant number 1022584).

Conflict of interest

The authors declare that they have no competing interests.

Ethical approval

No studies with human participants or animals were performed by any of the authors as part of this review.


  1. 1.
    Cella DF, Mahon SM, Donovan MI. Cancer recurrence as a traumatic event. Behav Med. 1990;16:15–22.CrossRefPubMedGoogle Scholar
  2. 2.
    Halldórsdóttir S, Hamrin E. Experiencing existential changes: the lived experience of having cancer. Cancer Nurs. 1996;19:29–36.CrossRefPubMedGoogle Scholar
  3. 3.
    Lagerdahl ASK, Moynihan M, Stollery B. An exploration of the existential experiences of patients following curative treatment for cancer: reflections from a UK sample. J Psychosoc Oncol. 2014;32(5):555–75.CrossRefPubMedGoogle Scholar
  4. 4.
    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;17:241–51.CrossRefPubMedGoogle Scholar
  5. 5.
    Kim Y, Carver CS, Spillers RL, et al. Dyadic effects of fear of recurrence on the quality of life of cancer survivors and their caregivers. Qual Life Res Int J Qual Life Asp Treat Care Rehab. 2012;21:517–25.CrossRefGoogle Scholar
  6. 6.
    Mellon S, Kershaw TS, Northouse LL, Freeman-Gibb L. A family-based model to predict fear of recurrence for cancer survivors and their caregivers. Psycho-Oncology. 2007;16:214–23.CrossRefPubMedGoogle Scholar
  7. 7.
    Simard S, Savard J. Screening and psychiatric comorbidity of clinical fear of cancer recurrence. 4th Canadian breast cancer research alliance reasons for hope scientific conference. Vancouver, Canada. 2008.Google Scholar
  8. 8.
    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;20:2651–9.CrossRefPubMedGoogle Scholar
  9. 9.
    Hodges L, Humphris G. Fear of recurrence and psychological distress in head and neck cancer patients and their carers. Psycho-Oncology. 2009;18:841–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Hart S, Latini D, Cowan J, et al. Fear of recurrence, treatment satisfaction, and quality of life after radical prostatectomy for prostate cancer. Support Care Cancer. 2008;16:161–9.CrossRefPubMedGoogle Scholar
  11. 11.
    Lebel S, Tomei C, Feldstain A, et al. Does fear of cancer recurrence predict cancer survivors’ health care use? Support Care Cancer. 2013;21:901–6.CrossRefPubMedGoogle Scholar
  12. 12.
    Llewellyn C, Weinman J, McGurk M, Humphris GM. Can we predict which head and neck cancer survivors develop fears of cancer recurrence? J Psychosom Res. 2008;65:525–32.CrossRefPubMedGoogle Scholar
  13. 13.
    Skaali T, Fossa SD, Bremnes R, et al. Fear of recurrence in long-term testicular cancer survivors. Psycho-Oncology. 2009;18:1273–80.CrossRefGoogle Scholar
  14. 14.
    Koch L, Jansen L, Brenner H, Arndt V. Fear of recurrence and disease progression in long-term (>5 years) cancer survivors—a systematic review of quantitative studies. Psycho-Oncology. 2013;22:1–11.CrossRefPubMedGoogle Scholar
  15. 15.
    Hodgkinson K. What is the psychosocial impact of cancer? In: Hodgkinson K, Gilchrist J, editors. Psychosocial care of cancer patients: a health professionals guide to what to say and do. Melbourne: Ausmed Publications; 2008.Google Scholar
  16. 16.
    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;27:6172–9.CrossRefPubMedGoogle Scholar
  17. 17.
    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-Oncology. 2008;17:1137–45.CrossRefGoogle Scholar
  18. 18.
    Crist JV, Grunfeld EA. Factors reported to influence fear of recurrence in cancer patients: a systematic review. Psycho-Oncology. 2013;22:978–86.CrossRefPubMedGoogle Scholar
  19. 19.
    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;7:300–22.CrossRefGoogle Scholar
  20. 20.
    Lee-Jones C, Humphris G, Dixon R, Hatcher MB. Fear of cancer recurrence—a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology. 1997;6:95–105.CrossRefPubMedGoogle Scholar
  21. 21.
    Witte K. Putting the fear back into fear appeals: the extended parallel process model. Commun Monogr. 1992;59:329–49.CrossRefGoogle Scholar
  22. 22.
    McGinty HL, Goldenberg JL, Jacobsen PB. Relationship of threat appraisal with coping appraisal to fear of cancer recurrence in breast cancer survivors. Psycho-Oncology. 2012;21:203–10.CrossRefPubMedGoogle Scholar
  23. 23.
    Rippetoe PA, Rogers RW. Effects of components of protection-motivation theory on adaptive and maladaptive coping with a health threat. J Pers Soc Psychol. 1987;52:596–604.CrossRefPubMedGoogle Scholar
  24. 24.
    Corter AL, Findlay M, Broom R, et al. Beliefs about medicine and illness are associated with fear of cancer recurrence in women taking adjuvant endocrine therapy for breast cancer. Br J Health Psychol. 2013;18:168–81.CrossRefPubMedGoogle Scholar
  25. 25.
    Park CL, Cho D, Blank TO, Wortmann JH. Cognitive and emotional aspects of fear of recurrence: predictors and relations with adjustment in young to middle-aged cancer survivors. Psycho-Oncology. 2013;22:1630–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Phillips KM, McGinty HL, Gonzalez BD, et al. Factors associated with breast cancer worry 3 years after completion of adjuvant treatment. Psycho-Oncology. 2013;22:936–9.CrossRefPubMedGoogle Scholar
  27. 27.
    Easterling DV, Leventhal H. Contributions of concrete cognition to emotion: neutral symptoms as elicitors of worry about cancer. J Appl Psychol. 1989;74:787–96.CrossRefPubMedGoogle Scholar
  28. 28.
    Hilton BA. The relationship of uncertainty, control, commitment, and threat of recurrence to coping strategies used by women diagnosed with breast cancer. J Behav Med. 1989;12:39–54.CrossRefPubMedGoogle Scholar
  29. 29.
    Liu Y, Pérez M, Schootman M, et al. Correlates of fear of cancer recurrence in women with ductal carcinoma in situ and early invasive breast cancer. Breast Cancer Res Treat. 2011;130:165–73.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Mishel MH. Uncertainty in chronic illness. Annu Rev Nurs Res. 1999;17:269–94.PubMedGoogle Scholar
  31. 31.
    Lebel S, Maheu C, Lefebvre M, et al. Addressing fear of cancer recurrence among women with cancer: a feasibility and preliminary outcome study. J Cancer Survivorship. 2014;8:485–96.CrossRefGoogle Scholar
  32. 32.
    Mishel MH, Germino BB, Gil KM, et al. Benefits from an uncertainty management intervention for African-American and Caucasian older long-term breast cancer survivors. Psycho-Oncology. 2005;14:962–78.CrossRefPubMedGoogle Scholar
  33. 33.
    Mast ME. Survivors of breast cancer: illness uncertainty, positive reappraisal, and emotional distress. Oncol Nurs Forum. 1998;25:555–62.PubMedGoogle Scholar
  34. 34.
    Eisenberg SA, Kurita K, Taylor-Ford M, et al. Intolerance of uncertainty, cognitive complaints, and cancer-related distress in prostate cancer survivors. Psycho-Oncology. 2015;24:228–35.CrossRefPubMedGoogle Scholar
  35. 35.
    Leventhal H, Diefenbach M, Leventhal EA. Illness cognition: using common sense to understand treatment adherence and affect cognition interactions. Cogn Ther Res. 1992;16:143–63.CrossRefGoogle Scholar
  36. 36.
    Sharpe L, Curran L. Understanding the process of adjustment to illness. Soc Sci Med. 2006;62:1153–66.CrossRefPubMedGoogle Scholar
  37. 37.
    Rabin C, Leventhal H, Goodin S. Conceptualization of disease timeline predicts posttreatment distress in breast cancer patients. Health Psychol. 2004;23:407–12.CrossRefPubMedGoogle Scholar
  38. 38.
    Koch L, Bertram H, Eberle A, et al. Fear of recurrence in long-term breast cancer survivors-still an issue. Results on prevalence, determinants, and the association with quality of life and depression from the cancer survivorship—a multi-regional population-based study. Psycho-Oncology. 2014;23:547–54.CrossRefPubMedGoogle Scholar
  39. 39.
    Lipkus IM, Klein WMP, Skinner CS, Rimer BK. Breast cancer risk perceptions and breast cancer worry: what predicts what? J Risk Res. 2005;8:439–52.CrossRefGoogle Scholar
  40. 40.
    Humphries G, Rogers S. AFTER and beyond: cancer recurrence fears and test of an intervention in oropharyngeal patients. Soc Sci Dent. 2012;2:29–38.Google Scholar
  41. 41.
    Humphris GM, Ozackinci G. The AFTER intervention: a structured psychological approach to reduce fears of recurrence in patients with head and neck cancer. Br J Health Psychol. 2008;13:223–30.CrossRefPubMedGoogle Scholar
  42. 42.
    Wells A, Matthews G. Modelling cognition in emotional disorder: the S-REF model. Behav Res Ther. 1996;34:881–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Cavanagh M, Franklin J. Attention training and hypochondriasis: preliminary results of a controlled treatment trial. World congress of cognitive and behavioral therapy. Vancouver, Canada 2000.Google Scholar
  44. 44.
    Baker P, Beesley H, Dinwoodie R, et al. ‘You’re putting thoughts into my head’: a qualitative study of the readiness of patients with breast, lung or prostate cancer to address emotional needs through the first 18 months after diagnosis. Psycho-Oncology. 2013;22:1402–10.CrossRefPubMedGoogle Scholar
  45. 45.
    Macleod C, Hagan R. Individual differences in the selective processing of threatening information, and emotional responses to a stressful life event. Behav Res Ther. 1992;30:151–61.CrossRefPubMedGoogle Scholar
  46. 46.
    Taylor L, Espie C, White C. Attentional bias in people with acute versus persistent insomnia secondary to cancer. Behav Sleep Med. 2003;1:200–12.CrossRefPubMedGoogle Scholar
  47. 47.
    Chan MW, Ho SM, Tedeschi RG, Leung CW. The valence of attentional bias and cancer-related rumination in posttraumatic stress and posttraumatic growth among women with breast cancer. Psycho-Oncology. 2011;20:544–52.CrossRefPubMedGoogle Scholar
  48. 48.
    Cook S, Salmon P, Dunn G et al. A prospective study of the association of metacognitive beliefs and processes with persistent emotional distress after diagnosis of cancer. Cogn Ther Res. 2014: 1–10.Google Scholar
  49. 49.
    Cook SA, Salmon P, Dunn G et al. The association of metacognitive beliefs with emotional distress after diagnosis of cancer. Health Psychol. 2014: No Pagination Specified.Google Scholar
  50. 50.
    Stanton AL, Danoff-burg S, Huggins ME. The first year after breast cancer diagnosis: hope and coping strategies as predictors of adjustment. Psycho-Oncology. 2002;11:93–102.CrossRefPubMedGoogle Scholar
  51. 51.
    Deimling GT, Bowman KF, Sterns S, et al. Cancer-related health worries and psychological distress among older adult, long-term cancer survivors. Psycho-Oncology. 2006;15:306–20.CrossRefPubMedGoogle Scholar
  52. 52.
    Wells A. Detached mindfulness in cognitive therapy: a metacognitive analysis and ten techniques. J Ration Emot Cogn Behav Ther. 2005;23:337–55.CrossRefGoogle Scholar
  53. 53.
    Lengacher C, Jonhson-Mallard V, Post-White J, et al. Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-Oncology. 2009;18:1261–72.CrossRefPubMedGoogle Scholar
  54. 54.
    Lengacher CA, Johnson-Mallard V, Barta M, et al. Feasibility of a mindfulness-based stress reduction program for early-stage breast cancer survivors. J Holist Nurs. 2011;29:107–17.CrossRefPubMedGoogle Scholar
  55. 55.
    Lengacher CA, Shelton MM, Reich RR, et al. Mindfulness based stress reduction (MBSR(BC)) in breast cancer: evaluating fear of recurrence (FOR) as a mediator of psychological and physical symptoms in a randomized control trial (RCT). J Behav Med. 2014;37:185–95.CrossRefPubMedGoogle Scholar
  56. 56.
    Hayes SC, Luoma JB, Bond FW, et al. Acceptance and commitment therapy: model, processes and outcomes. Behav Res Ther. 2006;44:1–25.CrossRefPubMedGoogle Scholar
  57. 57.
    Hayes S, Strohsahl K, Wilson K. Acceptance and commitment therapy; an experiential approach to behaviour change. New York: Guildford Press; 2003.Google Scholar
  58. 58.
    Fletcher L, Hayes S. Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness. J Ration Emot Cogn Behav Ther. 2005;23:315–36.CrossRefGoogle Scholar
  59. 59.
    Thewes B, Brebach R, Dzidowska M, et al. Current approaches to managing fear of cancer recurrence; a descriptive survey of psychosocial and clinical health professionals. Psycho-Oncology. 2014;23:390–6.CrossRefPubMedGoogle Scholar
  60. 60.
    Feros DL, Lane L, Ciarrochi J, Blackledge JT. Acceptance and commitment therapy (ACT) for improving the lives of cancer patients: a preliminary study. Psychooncology. 2013;22:459–64.PubMedGoogle Scholar
  61. 61.
    Rost AD, Wilson K, Buchanan E, et al. Improving psychological adjustment among late-stage ovarian cancer patients: examining the role of avoidance in treatment. Cogn Behav Pract. 2012;19:508–17.CrossRefGoogle Scholar
  62. 62.
    Zakowski SG, Valdimarsdottir HB, Bovbjerg DH, et al. Predictors of intrusive thoughts and avoidance in women with family histories of breast cancer. Ann Behav Med. 1997;19:362–9.CrossRefPubMedGoogle Scholar
  63. 63.
    Mishel MH. Uncertainty in illness. Image J Nurs Sch. 1988;20:225–32.CrossRefPubMedGoogle Scholar
  64. 64.
    Butow P, Bell M, Smith A, et al. Conquer fear: protocol of a randomised controlled trial of a psychological intervention to reduce fear of cancer recurrence. BMC Cancer. 2013;13:201.CrossRefPubMedPubMedCentralGoogle Scholar
  65. 65.
    Butow P, Kelly S, Thewes B, et al. Attentional bias and metacognitions in cancer survivors with high fear of cancer recurrence. Psycho-Oncology. 2015;24:416–23.CrossRefPubMedGoogle Scholar
  66. 66.
    Thewes B, Bell ML, Butow P. Fear of cancer recurrence in young early-stage breast cancer survivors: the role of metacognitive style and disease-related factors. Psycho-Oncology. 2013;22:2059–63.CrossRefPubMedGoogle Scholar
  67. 67.
    Persoskie A, Ferrer RA, Klein WM. Association of cancer worry and perceived risk with doctor avoidance: an analysis of information avoidance in a nationally representative us sample. J Behav Med. 2014;37:977–87.CrossRefPubMedGoogle Scholar
  68. 68.
    Sharpe L, Thewes B, Butow P. Attentional biases in cancer survivors: directions for future research. Psycho-Oncology. 2015;24:496.CrossRefPubMedGoogle Scholar
  69. 69.
    Lichtenthal WG, Tuman M, Beard C, et al. Development of attention and interpretation modification for fear of breast cancer recurrence (AIM-FBCR): preliminary findings. Psycho-Oncology. 2013;22:72–3.Google Scholar
  70. 70.
    Smith AB, Thewes B, Turner J et al. Pilot of a theoretically grounded psychologist-delivered intervention for fear of cancer recurrence (Conquer Fear). Psycho-Oncology 2015: n/a-n/a.Google Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Joanna E Fardell
    • 1
    • 2
  • Belinda Thewes
    • 1
    • 8
  • Jane Turner
    • 3
  • Jemma Gilchrist
    • 4
  • Louise Sharpe
    • 5
  • Allan ‘Ben’ Smith
    • 1
  • Afaf Girgis
    • 6
  • Phyllis Butow
    • 1
    • 7
    Email author
  1. 1.Psycho-Oncology Co-operative Research Group (PoCoG)University of SydneySydneyAustralia
  2. 2.Behavioural Sciences Unit, School of Women’s and Children’s HealthUniversity of New South WalesSydneyAustralia
  3. 3.Mental Health Centre, School of MedicineUniversity of QueenslandSt LuciaAustralia
  4. 4.Crown Princess Mary Cancer Centre, Breast Cancer InstituteWestmead HospitalSydneyAustralia
  5. 5.School of PsychologyUniversity of SydneySydneyAustralia
  6. 6.Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW MedicineUniversity of New South WalesSydneyAustralia
  7. 7.Chris O’Brien Lifehouse (C39Z), School of PsychologyThe University Of SydneySydneyAustralia
  8. 8.Department of Medical PsychologyRadboud University Medical CentreNijmegen (840)The Netherlands

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