RESULTS
By exploratory factor analysis and oblique rotation, the number of factors of the original scale decreased
from 7 to 5 and three of them have been renamed ("recurrence-related meta-cognitions," "emotion-focused
coping strategies," and "quality of life"). The overall Cronbach"s alpha coefficient of FCRI was 0.94,
and the item-total correlations ranged between 0.37 and 0.75. With respect to concurrent validity, except
for the "avoidance" subscale of IES, significant correlations (r=0.13?0.70; all p<0.01) were found between
FCRI factors and the total scores and subscales of other measures, similar to those in the original scale.
CONCLUSION
The Turkish version of FCRI has satisfactory psychometric properties, and it is eligible for use in studies
in Turkey.
Keywords: Fear of cancer recurrence; fear of cancer recurrence inventory; cancer
According to various research, it has been observed exthat
among the patients with different kinds of cancer,
39%-97% of them have experienced fear of cancer recurrence
(FCR) to a certain extent, 22%?87% experienced
FCR at a rate increasing from moderate to high
levels, and 0%-15% experienced FCR at a high level.
[6] It has also been observed that FCR is quite common
among patients with breast, ovarian, colon, lung,
and prostate cancers, and it continues for a long time
even after the end of the treatment, reduces the quality
of life, causes disruptions in the level of adjustment,
leads to emotional distress and anxiety, and negatively
affects the ability to make future plans.[
In the literature, it is mentioned that although low
levels of FCR result in emotional reactions that may be
defined as normal and temporary and provides being
alert against a potential threat or enables one to perform
some protective and preventive health behaviors,
high levels of FCR can end up in unrealistic, frequently
repeated, and continuous intrusive thoughts, provoke a
continuous seeking for security, or cause impairments
in functionality.[
Although there are many measurement tools in the
literature for evaluating FCR, according to a systematic
review study by Thewes, Butow, Zachariae, Christensen, Simard, and Gotay, wherein they evaluated
self-reported measures that measure FCR, it was concluded
that FCRI [
In our country, the number of studies on FCR is
limited. Moreover, no measurement tool for evaluating
FCR and the outcomes of this fear have been reported.
Therefore, considering Thewes and colleagues"
suggestions on FCRI [
Therefore, the major aim of this study was to conduct
the Turkish adaptation of FCRI and to investigate
whether FCRI is a valid and reliable tool for measuring
FCR in a group of cancer survivors. In this respect, it is
firstly expected that FCRI will demonstrate an acceptable
factor structure that is close to its original version
and similar internal consistency values. Within the
scope of the construct validity, a positive significant relationship
of FCR with both anxiety and depression is
expected, in the light of the findings of the abovementioned
literature. Moreover, a similar trend of relationship
is also proposed with intrusive thoughts accompanying
or preceding anxiety and depression and with
levels of hyperarousal, somatization, and avoidance,
where the latter three can be evaluated as the outcomes
of these intrusive thoughts and affective reactions of
anxiety and depression.
MEASURES
Triggers: Includes nine items about medical examinations
and television shows or newspaper articles on
cancer, which may act as triggers for FCR and thereby
are attempted to be avoided.
Severity: Includes nine items for assessing the perceptions
about the frequency, intensity, and duration
of FCR-perceived risk of recurrence and the beliefs in
the degree of normality of concerns about the risk of
recurrence.
Psychological Distress: Includes four items that test
four different emotions including anger, sadness, helplessness,
and anxiety that can be triggered by FCR.
Coping Strategies: Includes nine items where the
frequency of several coping strategies related to FCR
are evaluated [e.g., "I try to distract myself (do various
activities, watch television, read, work)" and "I try not
to think about it, get the idea out of mind"].
Functioning Impairments: Includes six items that
investigate functional impairments in the capacity to
make future plans or to set life goals in social or leisure
time activities due to FCR.
Insight: Three questions measure the degree of perceptions
in patients regarding the excessiveness or irrationality
of their fears.
Reassurance: Assesses the frequency of reassurance
or help-seeking behaviors related to FCR (e.g., "I examine myself to see if I have any physical signs of cancer"
and "I go to the hospital or clinic for an examination").
FCRI, is a Likert-type scale that ranges from 0 (not
at all/never) to 4 (all the time/a great deal). Increasing
scores received from the scale demonstrate a high level
of FCR.
The English version of the scale has similar psychometric
characteristics (For total scale scores, ?=0.96,
for test?retest r=0.88).[
Turkish Version of FCRI
Demographic and Medical Information Form
Patient Health Questionnaire-Somatic, Anxiety, and
Depressive Symptoms
Impact of Events Scale-Revised
Procedure
Data Analysis
Fear of Cancer Recurrence Inventory
FCRI, originally developed in French by Simard and
Savard [
After getting necessary permissions for the Turkish adaptation
on October 11, 2015 from Sébastien Simard,
one of the authors of the scale, the following steps were
followed for adapting the scale: First, the scale was
translated to Turkish by three English Linguists who
had a command over Turkish and English. Next, the
three translated versions were evaluated by two academicians
who had a comprehensive knowledge of the
field, in terms of convenience through a 5-point Likert
scale for each item, and these experts suggested changes,
if any. The average of the items was calculated for
each translation, and the translation with the highest
score was included in the scale. This form of the scale
was independently evaluated in terms of language convenience
by two Turkish philology experts, again using
a 5-point Likert scale of convenience. After all these
steps, the Turkish translation of the scale was put into
the final form and administered to a pilot sample who
evaluated the comprehensibility of the instructions,
items, and response scale and provided suggestions
for revision, if any, again using a 5-point Likert scale.
The pilot sample consisted of 10 patients with cancer
who were approached by a snowball sampling method
and whose primary cancer treatments were completed
(breast cancer, n=7; gynecologic cancer, n=1; genitourinary
cancer, n=1; and skin cancer n=1). All the participants
at the pilot step verbally stated that the scale
was clear and comprehensible. The convenience mean
of each item was calculated as at least ≥3 at each step,
and the back translation of the scale was done by two
experts different from those at the first step who also
had a command over the language. The back-translated impairtext
was sent to the authors of the original version, and
the adaptation study was started after receiving their
approval.
Besides the demographic variables, information concerning
medical status (type of cancer, radiotherapy,
chemotherapy completion time, follow-up frequency
etc.) was also questioned.
Originally developed by Kroenke, Spitzer, and Williams
[
In the literature, having been diagnosed with a type
of cancer is acknowledged as a traumatic experience,
which is known to end up with several psychological
symptoms [
After getting the ethical committee approval of İstanbul
University Ethical Committee of Social and Human
Scientific Studies on February 25, 2016, the adaptation
study was started; 92.7% (n=203) of the participants
filled in the batteries using a paper and pencil, and
the rest of them provided data by the online method.
Among the paper and pencil sample, 29.2% (n=64) of
the participants filled in the batteries on an individual
basis, whereas 70.3% (n=154) performed the administration after the researcher had read the questions. The
implementations performed with the paper and pencil
method took about 30 min. The data were combined as
no significant difference was observed (t(200)=-1.62,
p>0.05) between the mean FCRI scores of the participants
who filled in the batteries individually (M=36.77,
SD=21.13) and those who filled in with the help of the
researcher (M=30.95, SD=21.83).
First, an item analysis was conducted to determine the
discriminative values of the scale items. To test for the
construct validity of the scale, an exploratory factor analysis
with principal axis factoring method and oblique rotation
were implemented. Both the item and factor analysis
were conducted among the whole sample regardless
of the cancer type, as to the sample size criteria of item
number X minimum five subjects.[
The first factor of the scale, "triggers," consisted of seven items that explained 43.3% of the total variance.
The second factor named "functioning impairtextments" included two items and it explained 8.2% of the total variance.
In the third factor, there were four items that explained 4.7% of the total variance. In this factor, item number 28, which was in the "insight" factor, and the items numbered 15, 16, and 17, which were in the "severity" factor, in the original scale were gathered under one factor and called as "recurrence-related meta-cognitions."
The fourth factor consisted of five items and it constituted 4.6% of the variance. As the items were considered to represent emotion-focused coping strategies, the name "emotion-focused coping strategies" was given to the factor.
In the 5th factor, while item 30 and 29 were in the "insight" factor in the original scale, these two have been loaded together with the items that were in the "functioning impairments" factor in the original scale. In this case, as all the items in the 5th factor were thought to represent features related to quality of life, this factor was named as "quality of life," which included a total of six items and constituted 4.01% of the total variance.
The Cronbach"s alpha coefficient obtained from
the FCRI total scale was 0.94, and the item-total score
correlations varied between 0.37 and 0.75. The Cronbach"s
coefficient for "triggers," "functioning impairments,"
"recurrence-related meta-cognitions," "emotion-
focused coping strategies," and "quality of life"
subscales was found as 0.88, 0.90, 0.80, 0.83, and 0.84,
respectively. The item-total score correlations varied in
"triggers" factor between 0.61 and 0.73 in "recurrencerelated
metacognitions" factor between 0.58 and 0.70
in "emotion-focused coping strategies" factor between
0.40 and 0.75 and in "quality of life" factor between 0.48
and 0.74. In "functioning impairments" subscale, the
Cronbach"s coefficient value for both items was 0.81.
Finally, the mean FCRI score was found as M=33.11, SD=21.5. Factors, items, and psychometric properties
of the Turkish version of FCRI are presented in Table
As the largest subsample of the whole participants consisted of patients with breast cancer (n=116), before advancing in further analysis, an independent samples t-test was conducted to investigate whether FCRI scores obtained from the Turkish version changed as a function of cancer type where the patients with breast cancer were compared with the rest of the sample. It was observed that the two cancer groups did not differ in any of the scores measured using the Turkish version of FCRI (t(217)=0.96, p>0.05 for the total FCRI score; t(217)=0.16, p>0.05 for FCRI triggers; t(217)=0.94, p>0.05 for "functioning impairments"; t(217)=1.49, p>0.05 for "recurrence-related meta-cognitions"; t(217)=1.56, p>0.05 for "emotion-focused strategies" t(217)=1.09, p>0.05 for "quality of life"). Therefore, in the rest of the results section, the analysis run for the whole sample (the breast cancer sample and the other type cancer sample combined) and solely for the breast cancer subsample are presented.
Accordingly, a further analysis was conducted for patients with breast cancer. The Cronbach"s alpha coefficients for this subsample were 0.94 for FCRI total scale, 0.88 for "trigger," 0.82 for "functioning impairments," 0.81 for "recurrence-related meta-cognitions," 0.82 for "emotion-focused coping strategies" and 0.80 for "quality of life" subscales. Item-total correlations varied between 0.34 and 0.77. Moreover, the mean FCR score was M=34.33, SD=22.2.
Confirmatory Factor Analysis
In accordance with the criteria mentioned, both
for the whole sample and breast cancer subsample,
although the RMSEA and Χ2/df value of the original
version was below the values obtained in the Turkish
version, CFI and GFI values were higher in the Turkish
version of FCRI. Moreover, as the ECVI and AIC
values of the 5-factor model were lower, it is possible
to say that the data fits the Turkish version of the scale
better than the original version.
Concurrent Validity
For the whole sample, the highest correlation with
FCRI total score was obtained for "intrusion" subscale
of IES-R (r=0.70, p<0.01). As observed in the original study of FCRI, low to moderate significant correlations
were found between the Turkish version of FCRI"s
subscales and the total score and all the subscales of
IES-R (between r=0.12 and r=0.59), except for the
"avoidance" subscale. The correlations of "avoidance"
subscale of IES-R with the other factors, except for the
"emotion-focused coping strategies" and "quality of
life" of FCRI, were insignificant.
There were significant relations between all the
FCRI subscales and PHQ-SADS subscales. Among the
subscales of PHQ-SADS, "GAD-7 (anxiety)" showed
the highest and "PHQ-15 (somatization)" showed the
lowest correlation with FCRI total score. High correlations
were also observed between "GAD-7 (anxiety)"
and "quality of life" (r=0.55, p<0.01) and "recurrencerelated
meta-cognitions" (r=0.54, p<0.01) subscales of
FCRI. Finally, there was a significant relationship between
"PHQ-9 (depression)" subscale and FCRI total
score (r=0.47, p<0.01) and all the subscales (r=0.36?0.44,
p<0.01). As for the breast cancer subsample, a trend similar
to that of the whole was obtained for sample interand
intra-correlations, as can be seen at Table
Confirmatory factor analysis (CFA) was performed to
compare the original factor model of the scale and the
factor model obtained from the Turkish version in the
whole sample. A further CFA was done among breast
cancer subsamples as well. The models were tested using the maximum likelihood estimation method.
The acceptable fit indices criteria were expected to
be <5 for the proportion of the chi-square to degrees
of freedom (Χ2/df), >0.90 for GFI and comparative
fit index (CFI) [
To test the concurrent validity of FCRI within the
scope of construct validity, PHQ-SADS and IES-R
were used. The descriptive statistics of FCRI and its
subscales, PHQ-SADS subscales and IES-R subscales,
and the intra-correlations of FCRI sub-tests and their
inter-correlations with the concurrent validity scales
for both the whole sample and the breast cancer subsample
are presented in Table
In "triggers" factor, which is also the first factor in
the original scale, six of the items from the original subscale
that question the triggers of FCR were retained.
However, one item "I am afraid of cancer recurrence"
was indeed an item of the "severity" factor in the original
scale. Based on the assumption that experiencing
fear may be a trigger for FCR and as its factor loading
is high enough, this item was decided to be included
in the "triggers" factor. Indeed, this situation conforms
to Albert Bandura"s Reciprocal Determinism Principle
of Social Cognitive Theory, where it is postulated that
the internal factors like expectations and beliefs also
shape emotions and behavior.[
The second factor of the scale, which consisted of
two items was also named as "functioning impairments"
as these two items were exactly those in the
original "functioning impairments" subscale, which
however had four more related items. These remaining
four items, on the other hand, were loaded to the "quality
of life" factor, and this situation is discussed within
that factor later.
When we look at the third factor, it was observed
that one of the items came from the "insight" factor of
the original scale and the remaining items were from
the "severity" factor. After carefully analyzing the content
of these items, it seemed possible to consider them
as metacognitions with respect to cancer recurrence.
Thus, this newly generated factor in the Turkish version
was named as "recurrence-related meta-cognitions." For
example, the item 28 that was originally in the "insight"
factor and the items 15-17 that were originally in the
"severity" factor, represent metacognitive thinking related
to cancer recurrence, that is, thoughts on cancer
recurrence, in line with the components suggested in
the self-regulatory executive functions model (SREF).
This model proposes that cognitive attention syndrome,
which consists of self-focused attention, anxiety, attention
bias against rumination and threat information, and
maladaptive coping behavior (suppression, avoidance,
minimizing) is the major source of maintenance in distressing
emotions. There are research findings that suggest
FCR is also alleviated and maintained as a function
of cognitive attention syndrome described in SREF.[
When considering the fourth factor that consisted
of five items, four of the items were from the "psychological
distress," whereas item 34 was in the "coping
strategies" factor of the original scale. Together with
these five items, there seems to have emerged a new
structure where all the statements are thought to represent
specifically emotion-focused strategies to cope
with FCR (see Table
With respect to the fifth factor, while some of the
items of this factor originally took place in "insight"
factor (See items 29?30 in Table
To summarize, as a result of the factor analysis
of the Turkish version of FCRI, three of the original
subscales namely the "triggers," "functioning impairments,"
and "coping strategies" seemed to be preserved
in the Turkish version. Three new structures called as
"recurrence-related meta-cognitions," "emotion-based
coping strategies," and "quality of life" emerged from
the differing loads of the original items. This resulted
in the extinction of three original factors of "reassurance,"
"severity," and "psychological distress." However,
some items of these subscales were loaded under different
factors in the Turkish version. Nevertheless, as to
CFA, where it has been observed that the new version
fit the data better than the original version, it can be
suggested that the Turkish version of FCRI has an acceptable
factor structure.
Within the scope of concurrent validity of FCRI,
when the relation of FCRI total score and PHQ-SADS
and IES-R was considered, as expected, a moderate to
high level of relation was observed between "intrusion"
subscale of IES-R and "anxiety" and "depression" subscales
of PHQ-SADS.[
Our research has several limitations. The most
important limitation is that a great majority of the
participants answered the scale with the help of the
researcher, although it was a self-administered test. It
was decided to implement this method in accordance
with the preferences of the participants. Besides, due
to the difficulty of reaching the patient population in a
limited time, collecting some of the data via an online
method is another limitation of the research. However,
as no significant difference was observed between the
mean total FCRI score as a function of type of administration,
it can be concluded that the difference in the
type of administration did not have a significant effect
on the results. Another limitation is that the vast majority
of participants were patients with breast cancer.
This situation requires cautiousness while generalizing
the results for other cancer types and male sex as it
also led to an inequality in the sex frequency. Nevertheless,
this limitation of the study was attempted to
be overcome through repeating most of the analysis
within this breast cancer subsample where the results
revealed almost the same tendency as observed in the
whole sample. This can be accepted as an evidence for
the generic property of FCRI. Indeed, the patients with
breast cancer in the sample in the original study also
outweighed the other cancer types.[
Despite the above mentioned limitations, it was observed
that the Turkish version of FCRI had a factor
structure that was in compliance with the literature,
that is, its internal consistency and correlations with
the structures were as expected and at an acceptable
level. Due to these features, FCRI may be a tool that
contributes to research that will be performed in the
field as it evaluates FCR in a multidimensional manner.
In future studies, FCR and the effects of cultural
factors on this concept should be examined via qualitative
studies, and additionally the relationship of psychopathological
variables such as health anxiety and
personality patterns with FCR should be evaluated.
Appendix
Triggers-Tetikleyiciler
Functioning Impairments-Fonksiyonel Bozulmalar
Recurrence-Related Meta-cognitions Nükse İlişkin
Üst-bilişler
Emotion-Focused Coping Strategies-Duygu Odaklı
Baş Etme Stratejileri
Quality of Life-Yaşam Kalitesi
Acknowledgements: The authors would like to thank Prof.
Dr. Fuat Hulusi DEMİRELLİ for his invaluable supervision
in sampling criteria and data collection.
Peer-review: Externally peer-reviewed.
Authorship contributions: Concept - A.E.; Design -? A.E.,
H.Ö.S.B.; Supervision - H.Ö.S.B.; Materials - A.E., H.Ö.S.B.;
Data collection &/or processing - A.E.; Analysis and/or interpretation
- A.E., H.Ö.S.B.; Literature search - A.E.; Writing
- A.E., H.Ö.S.B.; Critical review - H.Ö.S.B.
The Turkish version of the items by the factors:
2 Doktorumla veya başka bir sağlık profesyoneli ile
bir randevu
3 Tıbbi tetkikler (örneğin; yıllık check-up, kan tahlilleri,
röntgenler)
5 Hasta birini görmek ya da hasta biri hakkında haber
almak
1 Kanser veya hastalık hakkındaki televizyon
programları veya gazete yazıları
7 Bir cenazeye gitmek ya da gazetenin ölüm ilanları
bölümünü okumak
10 Kanserin nüksetmesinden korkuyorum
22 Sosyal ya da boş zaman faaliyetlerimi ( Örneğin;
geziler, spor ve seyahat)
23 İş ya da günlük faaliyetlerimi
15 Kanser nüks ihtimalini ne kasar sık düşünüyorsunuz?
16 Kanser nüks ihtimali hakkında düşünmeye günde
ne kadar vakit harcıyorsunuz?
17 Ne kadar zamandır nüks ihtimali hakkında
düşünmektesiniz?
28 Kanser nüks ihtimali hakkında aşırı endişelendiğimi
hissediyorum.
19 Üzüntü, cesaret kırılması ya da hayal kırıklığı
20 Hüsran/engellenmişlik, kızgınlık veya öfke
18 Endişe, korku veya kaygı
21 Çaresizlik veya teslimiyet
34 Dikkatimi dağıtmaya çalışırım (Örn. çeşitli aktiviteler
yaparım, televizyon izlerim, okurum,
çalışırım).
26 Ruh halim ya da duygu durumumu
27 Genel olarak yaşam kalitemi
25 Gelecek ile ilgili planlar yapma ya da yaşam hedefleri
koyma becerimi
24 Eşim/sevgilim, ailem ya da yakın olduğum insanlarla
olan ilişkilerimi
30 Sanırım kanser nüks ihtimali hakkında kanser
teşhisi konmuş diğer insanlardan daha fazla
endişeleniyorum.
Conflict of Interest: The authors declare that there is no
conflict of interest.
