Graduation Year

2013

Document Type

Dissertation

Degree

Ph.D.

Degree Granting Department

Nursing

Major Professor

Cecile Lengacher

Keywords

Breast, Cancer, Fear, Recurrence, Survivorship

Abstract

The purpose of this cross-sectional, secondary data analysis was to explore, non-modifiable (stable) trait factors and modifiable (transient) state factors associated with fear of recurrence (FOR) in breast cancer survivors. Antecedent trait factors included demographic, clinical, social/behavioral factors, postulated mediator state factors included pain, fatigue, sleep disturbances, depression, state anxiety and perceived stress, and FOR was the outcome variable. The study used baseline data from an R-21 NCI funded (grant #R21CA109168) randomized control trial that examined the effects of mindfulness based stress reduction in early stage breast cancer recovery. Instruments from this study for antecedent variables (trait factors) included a Demographic and Clinical History Form, STAI; instruments used for mediator variable (state factors) included CES-D, STAI, PSS and MDASI subscales for pain and fatigue, sleep; the instruments used for the outcome variable FOR - CARS overall fear and nature of worry. The study sample included 82 women within 18 months post breast cancer treatment (stage 0, I, II, III). The Theoretical Model for psychosocial nursing research was used as a heuristic framework to examine the associations between trait factors and state factors and their mediating effects on FOR. Aim 1 explored the relationship between the antecedent (trait) variables associated with FOR (CARS overall fear and CARS nature of worry) using Pearson's and Spearman's correlations and analysis of variance (ANOVA). The findings revealed a negative association between age and FOR, CARS overall fear (r = -.236, p = .033) and FOR, CARS nature of worry (r = -.269, p = .015). Trait anxiety was positively associated with FOR, CARS overall fear (r = .433, p = .000) and FOR, CARS nature of worry (r = .358, p < 0.001). Race/ethnicity, education, marital status, employment, exercise, cancer stage, cancer treatment, exercise, smoking, drinking, hormone use and family history of breast cancer were not associated with FOR. Aim 2 explored the relationship between postulated mediator (state) variables, such as pain, fatigue, sleep disturbances, state anxiety, depression, perceived stress associated with FOR (CARS overall fear and CARS nature of worry) using Pearson's correlations. Findings revealed that depression (r = .347, p = .001), state anxiety (r = .467, p < 0.001), perceived stress (r = .365, p = .001) were positively associated with FOR, CARS overall fear of recurrence, and that pain (r = .220, p = .047), fatigue (r = .247, p = .025), state anxiety (r = .369, p = .001), and perceived stress (r = .410, p < 0.001) were positively associated with FOR, CARS nature of worry. Aim 3 used a mediation analysis (bootstrapping method) to examine the indirect effects of the statistically significant modifiable mediator state factors on the statistically significant antecedent trait factors and FOR (CARS overall fear and CARS nature of worry). With trait anxiety as the antecedent variable, state anxiety was indirectly associated (a mediating variable) with FOR, CARS overall fear (β = .1381, 95% CI = .0053 - .3050, p = .0299). Similarly, with a composite age/trait anxiety antecedent variable, state anxiety was indirectly associated (a mediating variable) with FOR, CARS overall fear (β = .5579, 95% CI = .1201 - 1.1669, p = .0157). Perceived stress and depression did not mediate the relationship between age and trait anxiety and concerns about recurrence overall fear. With trait anxiety as the antecedent variable, perceived stress was indirectly associated (a mediating variable) with FOR, CARS nature of worry (β = .5474, 95% CI = .0178 - 1.3298, p = .0294). Similarly, a composite age/trait anxiety antecedent variable, perceived stress was indirectly associated (a mediating variable) with FOR, CARS nature of worry (β = 2.0375, 95% CI = .1136 - 4.5976, p = .0495). Pain, fatigue and state anxiety did not mediate the relationship between age and trait anxiety and FOR nature of worry. This study suggests that breast cancer survivors who are anxious at baseline and report a current state of anxiety or perceived stress may be at higher risk for fears of breast cancer recurrence. Understanding the individual patient characteristics such as age, history of anxiety and current status of perceived stress or anxiety and the relationship with fears of recurrence allow nurses to offer individualized interventions for patients at greatest risk for psychological distress.

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