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Maryam changizi1*(phd candidate), Hooshang Mohammadian1(MSc) 

1  Abadan Faculty of Medical Sciences, Abadan, Iran 

 

Correspondence Address: 

Abadan Faculty of Medical Sciences, Abadan, Iran 

Phone: +98 9396489240 

Email : Mrs.changizi@yahoo.com 

Abstract  

 

Background: One of the most commonconcern is the fear of recurrence (FCR). our study aimed 

to investigate the fear of colorectal cancer and its impact on the survivors.  

Method  

The present study is a systematic review, which was initiated by searching “mesh” in databases 

of Scopus, Web of Sciences, PubMed and Embasein all field (titles, keywords, abstracts).finally4 

papers were selected .Qualitative evaluation was done through Combined Strobe Statement 

checklist.  

Result 

fear of cancer recurrence among survivors were ranging from medium to high. FCR had a 

relationship with the quality of life (QoL) and its dimensions (P<0.001) . lack of physical activity 

and gender (female more than male, OR=1.58) were more likely to face FCR.   

Conclusion 

According to the results, for the people with CRC experience, interventions should be planned 

with a view toward calming care, by increasing self-efficacy and social support.  

Key Words: Fear, Recurrence, Colorectal Cancer 

 

 

 

 

 

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Introduction 

Colorectal cancer is one of the most common cancers in men and women in the world, with 65% 

of this disease occurring in developing countries. 1.80 million of the cases and 862,000 of the 

deaths in the world occur due to this type of cancer. In the last decade, early diagnosis and 

therapeutic advances in cancer have led to an increase in cancer survival rates and consequently, 

in the number of cancer survivors (2,1). Survivors of colorectal cancer are not only complain 

about a series of physical problems, but they also experience a series of psychological problems 

such as fear of recurrence. [3]. One of the most common concerns in the survivors of this disease 

is the fear of relapse of the disease. The fear or the concern is the relapse of disease or its 

progression to the same organ or other organs of the body. [3]. The fear of common relapse is 

grievous, and almost 50% of the recoveries and 70% of the more vulnerable groups (such as 

young survivors) report high or moderate fears of relapse [4]. The fear of relapse is studied as a 

multidimensional structure and shows itself in a wide range of normal to high-level reactions [5]. 

At the normal level, the person is aware of the symptoms of the disease and takes enough care of 

himself. But if fear is more than normal, it can have undesirable effects on the quality of life, 

social activities and mental stress of the individuals and it can create intrusive thoughts [5-2]. 

The consequence is an increase in health care costs for patients. [4]. Due to the importance of 

this issue, our study is conducted to investigate the fear of colorectal cancer and its impact on 

survivors. 

Method 

The present study is a systematic review. In this study, the databases of scopus, web of science, 

pubmed and Embase were used and the key words of  mesh، (Colorectal 

Neoplasms)[Title/Abstract] OR Colonic Neoplasms)[Title/Abstract] OR Sigmoid 

Neoplasms)[Title/Abstract] AND colon cancer)[Title/Abstract] OR colorectal 

cancer)[Title/Abstract] OR Rectal Neoplasms)[Title/Abstract] OR Rectal cancer)[Title/Abstract] 

OR Anus Neoplasms)[Title/Abstract] OR Rectum Cancer)[Title/Abstract] OR Rectum 

Neoplasm)[Title/Abstract] OR colorectal tumors)[Title/Abstract] OR colon 

tumor)[Title/Abstract] OR rectum tumor)[Title/Abstract] OR rectal tumor)[Title/Abstract] OR 

Cancer of the Rectum)[Title/Abstract] OR Cancer of the colon)[Title/Abstract] AND 

fear)[Title/Abstract] AND recurrence)[Title/Abstract] OR  Relapse)[Title/Abstract] OR 

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Recrudescence[Title/Abstract]) were applied.  The criteria for entering the study included cross-

sectional descriptive articles with frequent reports on fears of cancer relapse, published in 

English.  After searching for databases in year 2019, at first, 1527 articles were found, that, after 

limiting human-based searches, the date of publication of the articles (the past 10 years) and the 

method of performing the study (descriptive cross-sectional), the number of articles reduced to 

3085 .in this range in all fields (titles, keywords, abstracts) we were obtained so many articles.  

  Many of these have not related to our subject and were removed after review. finally, 45 papers were 

selected. After removing repetitive and irrelevant items inconsistent with the entry variable, lack 

of summary and lack of access to the full article, four articles were selected. Qualitative 

evaluation of the articles was conducted through Combined Strobe Statement Checklist.  

figure 1. Flowchart for selection of primary study 

2- Limited to human samples 
3- Limited to 2010-2019  
4- Limited to English language  
5- Limited to cancer subject 
6- Limited to journal article 

7- Excluded because  

Irrelevance, whiteout abstract , 
 Unavailable full text, Unrelated results, 
 type of study. 

, 

 

 

Results 

The findings from this review showed that there is a fear of a return to disease in survivors of 

colorectal cancer and this score is moderate and upward. 

 The study of Fisher (2016) showed that 50% of the survivors, are afraid of disease’s relapse. In 

this study, women, in comparison with the men, (OR=1.58, CI95%=1.46-1.71) and younger 

people (in comparison with older ones) (OR=1.58, CI95%=1.46-1.71) and suburbanites 

(OR=1.14, CI95%= 1.05-1.23), in comparison with the other people, were more worried about 

disease relapse.  Also, FCR has a meaningful relationship with some of the health behaviors, 

including physical activity and smoking, and it has been found that smokers are more likely to 

experience a fear of disease relapse than non-smokers. More current smokers (OR= 1.34, CI= 

Stage 2: 1210 

Stage 3:546 

Stage 4: 498 

Stage 5: 349 

Stage 6: 308 

Stage 7: 45 

Stage 8: 4 

Stage 1: 1527 

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1.10- 1.58, p < 0.005), ex smoker (OR= 1.11, CI= 1.04- 1.21, p < 0.005). In this regard, it has 

been reported that patients who have recently been more under treatment, have showed more fear 

of disease relapse. (P < 0.001). In addition, this study showed that inactive patients are more 

afraid of disease relapse. [6]. 

Jae Custers (2015) reported that the rate of disease relapse in survivors who have filled out the 

CWS (Cancer Worry Scale) Questionnaire was 38% (1.1% low FCR, 2.9 High FCR) and they 

experienced a high level of fear. The relationship between FCR and life quality showed that 

people with high levels of fear have lower quality of life. (F(1,66)= 14.1, p<0.001).  Also, people 

with high level of fear of relapse, experience general anxiety disorder and cancer-related distress. 

(p<0.001). Feeling of anxiety and discomfort caused limitations in performing daily, F (1.66) = 

8.7, p <0.004), emotional (F (1.66) = 24, p <0.001), cognitive (F (1.66)) = 11.2, p <0.001) and 

social functions (F (1.66) = 22.9, p <0.001). Also, survivors with high FCR significantly had 

more problems with body image (F (1.70) = 13.7, p <0.001) and future prospects (F (1.70) = 

39.6, p <0.001) compared to people with lower levels of FCR [7]. 

Henfer (2017) aimed at determining the prevalence of fear of colorectal cancer reversal or its 

progression (FOP / FCR) using the Fear of Progression Questionnaire (FOP-Q-SF), which 

indicated that 36% of patients were worried about the disease's relapse or its progression. In 

addition, FOP / FCR is correlated with fatigue side effects (r (53) = 0.0477, p <0.001, diarrhea (r 

(53) = 0.424, p <0.001), nausea (r (53) = 0.540, p <0.001) and vomiting (r (53) = 0.359, p 

<0.001). In this study, the level of fear of patients was moderate to high. The study found that 

people suffering from cancer are trying to convince themselves that everything is good or they 

think positively, find solutions and replace those thoughts with pleasurable ones. (39,36,32%). In 

this regard, the reported strategies to counteract this status consisted of prayer, meditation and 

attempts to distract thought or not to think about it (75.61.57%) [8].  

Backer, in 2005, made use of CPILS(Cancer Problems in Living Scale) to show that 63.3% of 

patients with colorectal cancer are worried about the onset of illness and more than half of them 

are worried about the future and 37.5% felt vulnerability. See table No.1.  

 

 

 

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Table 1. Research Methodology and Features 

results Publication 
date  

Type of study Sample size  Place  QuestionnaireAuthor  

50% patient  reported fear of 
 their cancer returning. 

2016 cross-sectional 10969 UK PROMS Fisher A,et al. 

63.3% of patients with colorectal  
cancer worried about the disease's 
return. 

2005 cross-sectional Total = 752 
colorectal patient =65 

USA CPILS Baker F, et al. 

(36%) patient  suffered from FOP/FCR 
. 
Levels of FOP/FCR seemed to 
 be mostly moderate to high. 

2017 prospective & 
descriptive 

58 Germany FOP-Q-SF Hefner J ,et al. 

(38 %) patient  with  high  
levels of FCR, characterized by 
 higher levels of distress, post-
traumatic 
 stress symptoms, lower quality 
 of life. 

2016  211 Netherland CWS José A. E. 
Custers , et al. 

 

Discussion 

The aim of this study was to determine the frequency of fear of disease relapse and the effects of 

this fear on the life of patients and survivors of colorectal cancer. The results showed that 

differences in the scores of the individuals is an indication of fear of cancer relapse, which is in 

line with the other results [10]. Also, FCR was higher in women comparing with the men. 

Perhaps the reason lies in stereotypes. [11]. Also, the results of the study considering the 

relationship of FCR with age, showed that younger individuals are more afraid of disease relapse 

than the older ones. It seems that younger people have more expectations from life which is due 

to the social roles and the duties they have and they follow their treatment procedure seriously.  

In contrast, the older individuals are less expected and the time and the resources they have at 

their hand are less than the younger people[3]. Furthermore, the results of the study showed that 

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suburbanite were more afraid of cancer relapse. Perhaps, it is resulted from financial problems 

and lack of accession to treatment services. [3, 12]. Those individuals that have passed the early 

stages of the disease such as chemotherapy, developed more fear of the diseases which is 

consistent with the findings of the studies [13, 14]. In the present study, fear of cancer relapse is 

higher in smokers. This may be due to the extensive advertisements and advices in relation to the 

smoking and cancer by health care providers and specialists during the treatment procedure or 

before that, that are repeated for several times. Active patients expressed fewer fears of cancer. 

One of the strategies of third-party prevention and decelerating the reversal of symptoms of 

illness can be health promoting behaviors, including physical activities. [16] Active people have 

a better mental status and have greater power for dealing with the problems and may be less 

afraid of disease relapse. [17]. Based on the theory of Protection Motivation Theory, fear can 

affect the attitude and the behavior of the individual and it can motivate him to behave (18). The 

aim of the physical activities for cancer patients is to improve the quality of life, reduce its 

symptoms, including fatigue, depression and improvements in fitness indicators related to patient 

survival. [19]. In addition, patient’s involvement in health care and their active role in treatment 

is very helpful. [20] This decrease shows itself in almost all aspects of the quality of life 

(emotional, social, etc.). Lack of familiarity with cancer and post-treatment measures, daily 

functions and activities in humans are reduced and fear of death and anxiety about the future 

create obsessive thoughts that can affect the health of these individuals [21-24]. It seems that it is 

the result of low self-efficacy. In addition, meditation and spirituality are effective in controlling 

anxiety. The enhancement of self-efficacy is important in confronting with cancer. This is due to 

the positive meaningful relationship between self-efficacy and life quality and the meaningful 

statistical relationship between self-efficacy and areas of quality of life including physical health, 

mental health, social relationships and environment satisfaction. [25] Health education can be 

beneficial to cancer patients. [26]. 

Conclusion : 

According to the findings, the patient's back illness can lead to physical and psychological 

damage and, in general, a decrease in the quality of life in them and disruption of the function. 

Therefore, physical activities, patient activation in the treatment process, palliative care that 

includes role management, treatment and symptoms, and training on ways to seek social support, 

lifestyle changes to control bad health conditions, and facilitating access to services in 

marginalized individuals to continue The life of this group of people is recommended and it is 

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better that with the help of informal observant of patients health interventions are conducted in 

this direction.   

Limitations  

A large number of articles are found with the intended key word and the evaluation became 

complicated for us. Other limitations were the lack of application of the same questionnaire to 

report the fear of relapse in the study. 

 

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