Towards the validation of a new, blended theoretical model of fear of cancer recurrence
Abstract
Objective: Fear of cancer recurrence (FCR) is defined as “fear, worry, or concern about cancer returning or progressing”. To date, only the seminal model proposed by Lee‐Jones and colleagues has been partially validated, so additional model testing is critical to inform intervention efforts. The purpose of this study is to examine the validity of a blended model of FCR that integrates Leventhal's Common Sense Model, Mishel's Uncertainty in Illness Theory, and cognitive theories of worry. Methods: Participants (n = 106) were women diagnosed with stage I to III breast or gynecological cancer who were enrolled in a Randomized Controlled Trial of a group cognitive‐existential intervention for FCR. We report data from standardized questionnaires (Fear of Cancer Recurrence Inventory—Severity and Triggers subscales; Illness Uncertainty Scale; perceived risk of recurrence; Intolerance of Uncertainty Scale; Why do people Worry about Health questionnaire; Reassurance‐seeking Behaviors subscale of the Health Anxiety Questionnaire, and the Reassurance Questionnaire) that participants completed before randomization. Path analyses were used to test the model. Results: Following the addition of four paths, the model showed an excellent fit (χ2 = 13.39, P = 0.20; comparative fit index = 0.99; root mean square error of approximation = 0.06). Triggers, perceived risk of recurrence, and illness uncertainty predicted FCR. FCR was associated with maladaptive coping. Positive beliefs about worrying and intolerance of uncertainty did not predict FCR but led to more maladaptive coping. Conclusions: These results provide support for a blended FCR model.
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Theoretical models have identified behavioral and cognitive avoidance, and intolerance to uncertainty as critical etiological factors for FCR.
“Theoretical models have identified behavioral and cognitive avoidance, and intolerance to uncertainty as critical etiological factors for FCR [25–27].”
From Fear of cancer recurrence in breast cancer survivors carrying a BRCA1 or 2 genetic mutation : a cross-sectional study (2024) · cites this paper as [27]
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“(2018), who found that perceived risk of recurrence and illness uncertainty are associated with increased FCR, while coping style was found to be a consequence of FCR (with FCR leading to less cognitive avoidance) rather than a predictor of FCR, with the role of cognitive avoidance as a coping mechanism varying in fun…”
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“18 Triggers for FCR were numerous, consistent with existing FCR theoretical models 19–21 and similar to what has been found in cancer patients without a hereditary predisposition.”
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“The first is the Fear of Cancer Recurrence model, which puts forward that fear is a multidimensional construct in which external and internal cues (e.g. physician cues and symptom cues) increase patient’s perceived risk of recurrence (Lebel et al., 2018; Yang et al., 2022).”
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“One plausible explanation is that various meta‐cognitive factors, particularly negative beliefs regarding worry, exert a more significant influence on FCR than positive beliefs do [9].”
InfluentialHow does illness uncertainty impact recovery among patients with cardiac conditions?
Clarke, S. T., Murphy, B. M., Hester, R., & Jackson, A. C. (2022) · British Journal of Cardiac Nursing · doi:10.12968/bjca.2022.0102 · Cited by 8 · see citing works
Lebel, S., Maheu, C., Tomei, C., Mutsaers, B., Bernstein, L. J., Courbasson, C. M. A., Ferguson, S. E., Harris, C. A., Jolicoeur, L. J. A., Lefèbvre, M., et al. (2022) · Journal of Psychosocial Oncology Research and Practice · doi:10.1097/or9.0000000000000077 · Cited by 7 · see citing works
“In a validation study of our theoretical model, we found that uncertainty in illness moderated the relationship between triggers and FCR; that is, triggers were more likely to be associated with FCRwhen cancer survivors reported high levels of uncertainty in illness.([17]) Providing information about which physical sy…”
Self-citationLyu, M., Siah, C. J. R., Zhao, J., & Cheng, K. K. F. (2023) · European Journal of Oncology Nursing · doi:10.1016/j.ejon.2023.102360 · Cited by 6 · see citing works
Reed, S. C., Berrett‐Abebe, J., Whitney, R. L., Sarkar, S., & Bell, J. F. (2021) · Journal of Psychosocial Oncology Research and Practice · doi:10.1097/or9.0000000000000064 · Cited by 6 · see citing works
“Despite the clinical cut-off for FCR continuing to be debated and with the understanding that all measurement tools have some shortcomings,[105,106] we recommend that the Fear of Cancer Recurrence Inventory (FCRI) and FCRI-Short Form (FCRI-SF) be used as high-quality measurement tools for FCR. FCRI has excellent inter…”
BackgroundInfluentialFear of Recurrence Among Lung Cancer Survivors
Chen, Q., Weng, Y., Wang, F., Yang, X., Chen, W., & Huang, F. (2024) · Cancer Nursing · doi:10.1097/ncc.0000000000001339 · Cited by 6 · see citing works
Bartley, N., Best, M. C., & Butow, P. N. (2021) · Journal of Genetic Counseling · doi:10.1002/jgc4.1398 · Cited by 6 · see citing works
“Lebel et al. (2018) proposed that illness uncertainty impacts fear of cancer recurrence by moderating the relationship between triggers and perceived risk of recurrence.”
Backgroundvan Helmondt, S. J., van der Lee, M. L., Bisseling, E., Lodder, P., & Vries, J. D. (2021) · European Journal of Cancer Care · doi:10.1111/ecc.13431 · Cited by 6 · see citing works
“…structure of the FCRI may be suboptimal, there is increasing evidence for the multidimensional approach that underlies this questionnaire (Custers et al., 2017; Fardell et al., 2016; Lebel et al., 2018; Lee-Jones et al., 1997; Maheu et al., 2019; Simard & Savard, 2009; Simonelli et al., 2017).”
Lamarche, J., Ajmera, F., Avery, J., Sehabi, G., Lebel, S., & Nissim, R. S. (2025) · Current Oncology · doi:10.3390/curroncol32040209 · Cited by 5 · see citing works
Self-citationLamarche, J., Nissim, R., Avery, J., Wong, J., Maheu, C., Lambert, S. D., Laizner, A. M., Jones, J., Esplen, M. J., & Lebel, S. (2024) · Pilot and Feasibility Studies · doi:10.1186/s40814-024-01567-4 · Cited by 4 · see citing works
“1) [47] that aims to address key vulnerability factors such as internal and external triggers, exaggerated perceived risk of recurrence, hyper-focus on ambiguous physical sensations, maladaptive coping, uncertainty around cancer and its treatments or care, intolerance of uncertainty, and beliefs…”
Self-citationLebel, S., Chu, A. K., Gourgues, F., Kearns, E., Prudent, A., Sehabi, G., Sehabi, W. Y., Beattie, S., Garland, S. N., Harris, C. A., et al. (2025) · Psycho-Oncology · doi:10.1002/pon.70293 · Cited by 4 · see citing works
“FORT is based on an empirically supported theoretical model of FCR [23] and has 6 goals: (1) help participants identify their triggers of FCR; (2) teach cognitive restructuring to deal with cata-strophic thoughts around recurrence and challenge positive beliefs about worrying; (3) decrease…”
Self-citationE-Health Intervention for Fear of Cancer Recurrence
Lyhne, J. D., Smith, A. B., Timm, S., Klein, B., Thewes, B., Girgis, A., Bamgboje‐Ayodele, A., Beatty, L., Fardell, J. E., Fink, P., et al. (2025) · JAMA Network Open · doi:10.1001/jamanetworkopen.2025.42112 · Cited by 5 · see citing works
Lamarche, J., Nissim, R. S., Avery, J., Wong, J., Maheu, C., Lambert, S., Laizner, A. M., Jones, J. M., Esplen, M. J., & Lebel, S. (2025) · Psycho-Oncology · doi:10.1002/pon.70084 · Cited by 4 · see citing works
Self-citationMichel, A., Dorval, M., Chiquette, J., & Savard, J. (2024) · Hereditary Cancer in Clinical Practice · doi:10.1186/s13053-024-00285-5 · Cited by 3 · see citing works
“Theoretical models have identified behavioral and cognitive avoidance, and intolerance to uncertainty as critical etiological factors for FCR [25–27].”
BackgroundBrearty, C. M., Bisaillon, L., Dorval, M., Nabi, H., Desbiens, C., Lemieux, J., Théberge, V., Baghdadli, A., Lauzier, S., & Savard, J. (2024) · Current Oncology · doi:10.3390/curroncol31020059 · Cited by 3 · see citing works
“Intolerance of uncertainty is a central construct in recent theoretical models of FCR etiology [12–14].”
BackgroundInfluentialBrown, S. L., Hope‐Stone, L., van der Voort, N., Hussain, R. N., Heimann, H., Coventry, W. L., & Cherry, M. G. (2024) · British Journal of Health Psychology · doi:10.1111/bjhp.12719 · Cited by 3 · see citing works
Fear of Cancer Recurrence in Women with Gynecological Cancer: A Systematic Review
Büyükokudan, Ş., & Körükcü, Ö. (2024) · Psycho-Oncologie · doi:10.32604/po.2024.046627 · Cited by 4 · see citing works
Fear of cancer recurrence in patients undergoing germline genome sequencing
Bartley, N., Davies, G., Butow, P. N., Napier, C. E., Schlub, T. E., Ballinger, M. L., Thomas, D. M., Juraskova, I., Meiser, B., & Best, M. C. (2021) · Supportive Care in Cancer · doi:10.1007/s00520-021-06311-9 · Cited by 2 · see citing works
“Recent theoretical reviews and discussions have begun focusing on the interplay between FCR and uncertainty in illness [3, 13, 34].”
BackgroundConradi, H. S. W., Nguyen, T., Lawal, O. A., & Carlson, L. E. (2025) · Global Advances in Integrative Medicine and Health · doi:10.1177/27536130251367051 · Cited by 1 · see citing works
Lee, V. (2023) · doi:10.1093/oso/9780197667934.003.0003 · Cited by 1 · see citing works
Harris, C. A., Giguère, L., Chu, A. K., Lamarche, J., Langmuir, T., Menelas, K., Rutkowski, N. A., Sehabi, G., & Lebel, S. (2025) · Psycho-Oncology · doi:10.1002/pon.70140 · Cited by 1 · see citing works
“FORT is based on a blended theoretical model of FCR [21] aiming to target key vulnerability factors such as internal and external triggers, exaggerated perceived risk of recurrence, hyper‐focus on ambiguous physical sensations, maladaptive coping, uncertainty around cancer and its treatments or…”
Self-citationPreliminary Validation of the Cancer Worry Scale in Pediatric Survivors of Childhood Cancer
Russell, K. B., Patton, M., Verhesen, T., Forbes, C., Stokoe, M., Guilcher, G. M. T., Tomfohr‐Madsen, L. M., & Schulte, F. (2025) · Pediatric Blood & Cancer · doi:10.1002/pbc.31967 · Cited by 1 · see citing works
“Anxiety and depression are related but distinct emotionalconstructsthatfrequentlyco-occurwithFCR[3],while intolerance of uncertainty has been identified as a core cognitive contributor to FCR [31].”
InfluentialManaging, not lessening, uncertainty: a novel mind–body intervention for fear of cancer recurrence
Christie, A. J., Bolden, C., Park, E. R., Yeh, G. Y., O’Cleirigh, C. M., Peppercorn, J. M., Denninger, J. W., Hirschberg, A., Lee, H., Markwart, M., et al. (2025) · Journal of Cancer Survivorship · doi:10.1007/s11764-025-01886-2 · Cited by 1 · see citing works
“Intolerance of uncertainty is a more recent addition to the literature examining factors related to FCR, and previous studies find similar positive cross-sectional associations [27, 28].”
Akboğa, Y. E., Türkel, N. N., Demirci, A., & Ertek, İ. E. (2025) · Neurological Sciences · doi:10.1007/s10072-025-08507-x · Cited by 1 · see citing works
“According to the mixed model developed by Lebel and colleagues to explain the fear of recurrence in cancer patients, IU may influence fear of relapse in MS patients both directly and indirectly through negative illness perceptions [51].”
Clarke, S. T., Murphy, B. M., Grande, M. R. L., Rogerson, M. C., Kovacic, J. C., Hesselson, S., Iismaa, S. E., Graham, R. M., Hester, R., & Jackson, A. C. (2026) · European Journal of Cardiovascular Nursing · doi:10.1093/eurjcn/zvag090 · Cited by 1 · see citing works
“31,32 While these studies indicate that illness uncertainty and FoRP are re-lated, they do not indicate how this relationship contributes to ongoing mental health outcomes, such as anxiety, depression, and distress.”
Maheu, C., Singh, M. D., Courbasson, C. M. A., Sarvanantham, S., Lambert, S., Dubois, S., Charbonneau, A., Grantner, R., Baku, L., McCready, D. R., et al. (2023) · Canadian Oncology Nursing Journal · doi:10.5737/23688076331101 · Cited by 1 · see citing works
Self-citationKapfhammer, H. (2022) · Springer eBooks · doi:10.1007/978-3-662-65873-4_12
Maheu, C., Singh, M. D., Courbasson, C. M. A., Sarvanantham, S., Lambert, S., Dubois, S., Charbonneau, A., Grantner, R., Baku, L., McCready, D. R., et al. (2023) · Canadian Oncology Nursing Journal · doi:10.5737/23688076331108
Self-citationPeur de la récidive du cancer en contexte pandémique chez les femmes atteintes d'un cancer du sein
Brearty, C. M., Bisaillon, L., Lauzier, S., & Savard, J. (2023) · Psycause revue scientifique étudiante de l École de psychologie de l Université Laval · doi:10.51656/psycause.v13i1.51849
“…la PRC est associée à l’intolérance à l’incertitude, soit une difficulté à tolérer les situations caractérisées par de l’incertitude, laquelle est d’ailleurs au cœur de certains modèles étiologiques de la PRC (Curran et al., 2020; Kyriacou et al., 2017; Lebel et al., 2018; Savard et al., 2018).”
Sierra-Murguía, M. A., Bazan-Muñoz, J., Crisóstomo-Rosas, S., Lebel, S., Maheu, C., Rivera-Olvera, I., & Gálvez‐Hernández, C. L. (2025) · Psicooncología · doi:10.5209/psic.101690
Self-citationEffects of Fear of Cancer Recurrence on Coping Among Women With Cancer
Son, S., & Lee, S. H. (2025) · Cancer Nursing · doi:10.1097/ncc.0000000000001517
Alberts, N. M., Stratton, K. L., Leisenring, W. M., Pizzo, A., Lamoureux, É., Alschuler, K. N., Flynn, J., Krull, K. R., Jibb, L., Nathan, P. C., et al. (2025) · Journal of Cancer Survivorship · doi:10.1007/s11764-025-01865-7
“Cancer diagnosis and treatment-related variables were unrelated to elevated intolerance of uncertainty, which is consistent with initial studies among adults on cancer treatment [16, 17].”
The experience of fear of recurrence in Mexican breast cancer survivors: a qualitative study
Bazan-Muñoz, J., Lebel, S., Monroy-López, A., Riveros-Rosas, A., Caballero-Suárez, N. P., Bermúdez-Pavón, M., & Gálvez‐Hernández, C. L. (2025) · Journal of Psychosocial Oncology Research and Practice · doi:10.1097/or9.0000000000000182
Self-citationEyrenci, A., Ertuna, L., & Bahçivan, O. (2025) · Psycho-Oncology · doi:10.1002/pon.70345
“FORT provides an FCR‐focused adaptation of CBT that integrates meaning‐ centered and exposure‐based strategies to help survivors tolerate uncertainty, confront fears of mortality, and re‐engage with valued life domains [5, 6].”
Living Fully Despite Fear of Recurrence
Jessa Landmann, N. D. (2026) · doi:10.1002/9781394381401.ch13
Flesher, E. A., Armstrong, G. M., Flynn, J. S., Sachner, L., Blake, A., Jones, A., Webster, R. T., Humphrey, C. E., Jurbergs, N., Hsu, C.-W., et al. (2026) · Current Oncology · doi:10.3390/curroncol33030133
“Models of FCR posit that cognitive factors, such as illness perception and appraisals, promote or underlie development of FCR [32,33], offering a potential mechanism through which education may influence FCR.”
InfluentialNeves, M. C., Custers, J. A. E., Prins, J. B., Nunes, F., Monteiro, S. O. M., & Sales, C. (2026) · Journal of Adolescent and Young Adult Oncology · doi:10.1177/21565333261451809
Holy, C., Brinson, J., Gibson-Haerle, J., Russell, K. B., Abbott, L. S., Giguère, L., Givogue, A., Guilcher, G. M. T., Heathcote, L. C., Johnson, E., et al. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1815418
“Its therapeutic framework is informed by a blended FCR theoretical model developed and empirically validated through path analyses (Lebel et al., 2018).”
Self-citationMiedo a la recurrencia del cáncer de mama en sobrevivientes: Revisión de alcance
Silva, P. C., & Jiménez, M. O. (2026) · SANUS · doi:10.36789/sanus.vi22.609
- Authors
- Lebel, S., Maheu, C., Tomei, C., Bernstein, L. J., Courbasson, C., Ferguson, S., Harris, C., Jolicoeur, L., Lefebvre, M., Muraca, L., Ramanakumar, A. V., Singh, M., Parrott, J., & Figueiredo, D.
- Affiliations
- University of Ottawa (CA)
- McGill University (CA)
- University of Toronto (CA)
- Cognitive Behavioural, Dialectic Behavioural, and Humanistic Therapy Centre Toronto Ontario Canada
- Ottawa Hospital (CA)
- The Ottawa Hospital Ottawa Ontario Canada
- Mount Sinai Hospital (CA)
- McGill University Health Centre (CA)
- York University (CA)
- Corresponding author
- Lebel, Sophie
- ORCID
- Venue
- Psycho-Oncology
- Publisher
- Wiley
- Published
- 2018-09-27
- Volume
- 27
- Issue
- 11
- Pages
- 2594-2601
- ISSN
- 1057-9249 (ISSN-L)
- 1099-1611
- OpenAlex
- W2889709523
- Cited by
- 82
- References
- 39
- Citations by year
- 2026: 6 · 2025: 16 · 2024: 15 · 2023: 12 · 2022: 8 · 2021: 13 · 2020: 8 · 2019: 3 · 2018: 1
- FWCI
- 2.34
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Psycho-Oncology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Canadian Cancer Society Research Institute (702589)
- Topics
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Women's cancer prevention and management
- Keywords
- fear of cancer recurrence, Mishel's uncertainty in illness theory, illness uncertainty, intolerance of uncertainty, reassurance seeking, maladaptive coping, breast cancer, gynecologic cancer, model validation
- MeSH terms
- Cancer Survivors, Adaptation, Psychological, Adult, Anxiety, Breast Neoplasms, Fear, Female, Genital Neoplasms, Female, Humans, Middle Aged, Models, Theoretical, Neoplasm Recurrence, Local, Phobic Disorders, Surveys and Questionnaires, Uncertainty
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