Introduction
Cancer is increasingly viewed as a chronic condition manageable for long periods, thanks to advances in diagnosis and treatment options (Miller et al., 2022; Phillips & Currow, 2010; McCorkle et al., 2011). Despite these improvements, cancer’s profound physical, emotional, and mental impacts often make the experience traumatic (Andrykowski & Cordova, 1998; Cordova et al., 2017). Adding complexity to this scenario is the notion of ‘trauma centrality,’ where significant events like a cancer diagnosis become pivotal to one’s self-identity and world perception (Cook et al., 2021). Simultaneously, ‘fear of cancer recurrence (FCR)’ introduces another dimension, characterized by intrusive thoughts and concerns about the disease returning. FCR is a distressing constellation of worry, rumination, or concern about the potential for cancer to recur or progress (Fodor et al., 2023; Lebel et al., 2016). A recent meta-analysis suggests that the fear of cancer recurrence is associated with various prevalent mental health issues (Podina et al., 2023a). In our view and our prior results, fear of cancer recurrence is a cognitive concept or driven by a cognitive core concept, intrusive thoughts (Fodor et al., 2023).
A recent study by Podina et al. (2023b) highlighted that the time elapsed since diagnosis is a determinant of emotional and psychological health in cancer survivors. Short-term survivors (< 5 years post-diagnosis) exhibited higher depression and anxiety indicators than their long-term counterparts (≥ 5 years post-diagnosis; Eyl et al., 2018; Koch et al., 2013). Furthermore, the duration since diagnosis significantly influences FCR levels and the degree to which cancer-related trauma centralizes in a survivor’s life (Eyl et al., 2018; Thong et al., 2013). Studies suggest that the further survivors are from their diagnosis, the less they fear recurrence (Lebel et al., 2016; Simard et al., 2013).
The time since diagnosis also intersects with trauma centrality (Easley, 2017). For short-term survivors, the cancer experience often dominates their existence as they adjust to their new reality (Brennan, 2001). Cordova et al. (2017) found that within the first year post-diagnosis, cancer was central to breast cancer survivors’ self-identity.
Conversely, for long-term survivors, centrality of cancer may diminish as they re-establish routines and deal with the after effects of the disease process (Koch et al., 2013; Mehnert et al., 2013). Koch et al. (2013) also noted a positive correlation between FCR and trauma centrality among breast cancer survivors, suggesting that higher FCR is associated with viewing the cancer experience as a core part of self-identity. Moreover, the continuous presence of FCR in one’s thoughts may amplify its importance and centrality (Brosschot et al., 2006; Wegnererber 1992).
The ABC cognitive model (Beck, 1976; Carlson & Knaus, 2013) offers insight into how Fear of Cancer Recurrence (FCR) impacts trauma centrality. Triggered by the time since diagnosis, FCR can induce thoughts such as “cancer can come back at any time,” leading to anxiety or fear (B), which in turn results in behaviors like seeking reassurance or body checking for signs of recurrence (C). This cyclical process (A-B-C) may lead to FCR becoming a central element of one’s identity. This is the theoretical reasoning from which we initiated our research. Admittedly, our research does not delve into C (behaviors and emotions) but rather investigates the A – Belief 1 – Belief 2 chain, represented in the current study by the time since diagnosis (A), fear of cancer recurrence (B1), and trauma centrality (B2). This approach introduces a conceptual novelty in cancer survivorship research, which is typically informed by the well-established, yet behaviorally focused, fear of cancer recurrence conceptualizations that seldom highlight beliefs and rarely conceptualize fear of cancer recurrence as a cognitive homologue of intrusive thoughts (worry and rumination) as argued by Fodor et al. (2023).
Turning from psychological repercussions to the diagnostic stage, early-stage survivors (stage 1 or 2) may be more susceptible to FCR’s impact on their self-identity (Thewes et al., 2012; Tran et al., 2022) relative to late stage survivors (stage 3 or 4). This is consistent with previous findings that have highlighted the unique challenges faced by early-stage survivors, such as increased uncertainty and vulnerability, which lead to increased preoccupation with FCR (Tran et al., 2022; Thewes et al., 2012) and a stronger impact on self-identity and meaning attribution to the traumatic event.
Finally, this paper aims to evaluate through a hypothesized moderated mediation the relationship between the above-mentioned linked concepts; time since diagnosis, FCR, and trauma centrality, considering also the stage of cancer diagnosis.
Hypothesis 1
Hypothesis 2
(H2) suggests that the indirect effect of time since diagnosis on trauma centrality will vary by cancer stage. Specifically, those who receive a diagnosis at an early stage may exhibit a lower level of fear over the possibility of cancer recurrence, as well as reduced attention to the trauma centrality of their diagnosis (Thewes et al., 2012), in comparison to those who are diagnosed at, more advanced stages. Hence, we expect a moderation on the b path.
Methods
Participants
According to Fritz & MacKinnon (2007), the required sample size to detect a small to medium mediated effect (d = 0.26) using Percentile bootstrap consists of 162 participants. The initial sample size of this study consisted of 235 participants. One participant was excluded for not meeting the age criteria. The final sample size was comprised of 234 adult participants diagnosed with cancer, who were recruited via social media platforms and the TEMERARII community.
Participants provided their consent and were offered incentives for their involvement. A significant portion of participants reported experiencing clinical levels of Fear of Cancer Recurrence (54.27%). The most prevalent cancer types within the cohort were breast cancer (22.22%) and lymphoma (14.95%). Encouragingly, the majority of participants had entered remission (66.2%), with a vast majority showing no signs of cancer recurrence (83.8%).
In terms of treatment modalities, the majority of participants underwent surgery combined with chemotherapy or radiotherapy (41.45%), while others received chemotherapy alone (18.80%), chemotherapy in conjunction with radiotherapy (13.67%), or surgery exclusively (2.99%). Additionally, various other combinations of treatments were reported by 23.07% of participants, such as chemotherapy paired with hormone therapy or immunotherapy.
Instruments
Fear of Cancer Recurrence
The Fear of Cancer Recurrence Inventory – Short Form (FCRI-SF) is corresponds to the 9-item severity subscale of the Fear of Cancer Recurrence Inventory (FCRI; Simard & Savard, 2009). All items are measured on a 5-point Likert scale from 0 (i.e., ‘Not at all’) to 4 (i.e., ‘All the time’). In the current sample, the reliability for the FCRI-SF was excellent (α = 0.90).
Trauma Centrality
The Centrality of Event Scale (CES; Berntsen & Rubin, 2006) is an instrument used to assess the impact and significance of a traumatic event on the person’s identity and meaning attribution to life. The short form of CES contains 7 items measured on a 5-point Likert scale from 1 (i.e., ‘Totally disagree’) to 5 (i.e., ‘Totally agree’). The scale has a good reliability in the current sample (α = 0.83) consistent with previous research (α = 0.88; see Berntsen & Rubin, 2006).
Cancer Stage at Diagnosis
Procedure
The study was conducted online, utilizing a survey administered through QuestionPro software (QuestionPro, 2024), ensuring a wide reach and easy accessibility for participants. Moreover, the research was approved by the Ethics Committee of the University of Bucharest (Date 14.08.2021/No. 51). Prior to participation, all respondents were informed about the study’s objectives and their rights as participants, with informed consent obtained from each individual.
Analytic Strategy
Preliminary, we ran Pearson inter-variable correlations for fear of cancer recurrence and trauma centrality scores using SPSS (V.25) software.
The multivariate analysis of variance (MANOVA) was used to investigate the differences in study variables (i.e., fear of cancer recurrence and trauma centrality) between groups of short- and long-term cancer survivors and early- versus late stages of cancer respectively.
For the post-hoc analyses we used the Bonferroni adjustment.
Additionally, we employed the PROCESS macro for SPSS, Version 4.0 (Hayes, 2017), which facilitated the execution of simple mediation and moderation analyses, utilizing models 4 and 1. This stage allowed us to examine the direct and indirect relationships between time since diagnosis, fear of cancer recurrence, and trauma centrality, with the stage of diagnosis as a moderator.
Subsequently, we expanded our analysis to include second-order moderated mediation, using model 14 of the PROCESS macro. This advanced model enabled us to dissect the conditional indirect effects of our model.
Hypotheses were tested using the PROCESS macro for SPSS (Hayes, 2013) utilizing bias-corrected bootstrapping with 5000 resamples.
Results
Preliminary Analyses
The sample characteristics are presented in Table 1.
Table 1
Characteristics of the sample (N = 234)
N | % | M(SD) | Range | |
|---|---|---|---|---|
Age (years) | 234 | - | 35.58(14.70) | 18–70 |
Gender | ||||
Female | 183 | 78.2 | ||
Male | 50 | 21.4 | ||
Other | 1 | 0.4 | ||
Education | ||||
Primary school | 3 | 1.3 | ||
Elementary/professional school | 19 | 8.1 | ||
Highschool | 85 | 36.3 | ||
Graduate | 95 | 40.6 | ||
Postgraduate | 32 | 13.7 | ||
Marital status | ||||
Single | 59 | 25.2 | ||
In a relationship | 55 | 23.5 | ||
Married/or I live with the partner | 107 | 45.7 | ||
Widowed, divorced or separated | 13 | 5.6 | ||
Residence | ||||
Rural | 74 | 31.6 | ||
Urban | 160 | 68.4 | ||
Age at diagnosis (years) | 234 | - | 28.50(18.25) | 1–68 |
Time since diagnosis (categorical) | ||||
Short-term cancer survivors | 102 | 43.6 | ||
Long-term cancer survivors | 132 | 56.4 | ||
Cancer stage at diagnosis | ||||
Early stage | 140 | 59.8 | ||
Late stage | 94 | 40.2 |
The results for the two-tailed Pearson correlations are presented in Table 2. The normality assumption was met, with skewness and kurtosis values between − 1/1 (George & Mallery, 2013) for both fear of cancer recurrence (Sk = 0.18: K = − 0.81) and trauma centrality (Sk = − 0.87; K = 0.49).
Table 2
Inter-variable Pearson correlations
M(SD) | Min-Max | 1 | 2 | |
|---|---|---|---|---|
1. Fear of cancer recurrence | 13.96(8.57) | 0–35 | - | 0.32** |
2. Trauma centrality | 3.88(0.89) | 1–5 | 0.32** | - |
MANOVA Analyses
Firstly, using the time since diagnosis as fixed factor, Box’s test of equality of covariances was significant (Box’s M = 10.25, p = .02); the Levene’s test for equality of error variances was non-significant for Fear of cancer recurrence (p = .69), but significant for Trauma centrality (p = .002). Due to the assumptions for multivariate normality and homogeneity not being met, we used Pillai’s Trace criterion for multivariate tests (Pillai’s Trace = 0.30, F(2, 231) = 3.57, p = .03). Moreover, the normality of data and the number of participants - supported by the Central Limit Theorem; Rencher, 2002) -, ensure that the MANOVA analysis can be performed.
The univariate results for the time since diagnosis groups showed a significant difference for fear of cancer recurrence (F(1,233) = 6.80, p = .01) but not for trauma centrality (F(1,233) = 1.92, p = .17). The pairwise comparisons showed that short-term cancer survivors (N = 102; M = 15.60, SE = 0.84) indicated significantly higher fear of cancer recurrence (Mdiff= 2.91, p = .01), compared to long-term cancer survivors (N = 132; M = 12.69, SE = 0.74).
For cancer stage as a fixed factor, Box’s test of equality of covariances was significant (Box’s M = 10.06, p = .02); the Levene’s test for equality of error variances was non-significant for Fear of cancer recurrence (p = .19) and slightly significant for Trauma centrality (p = .048). Due to the assumptions not being met, we used Pillai’s Trace criterion for multivariate tests (Pillai’s Trace = 0.02, F(2, 231) = 2.70, p = .07). As the multivariate tests showed non-significant overall differences among groups, we did not report the univariate tests for study outcomes by cancer stage.
Mediation Analysis
The results showed that the mediation model explained approximately 10% of the variance in trauma centrality (F(2,231) = 13.42, p < .001) and a significant indirect effect of time since diagnosis on trauma centrality by fear of cancer recurrence (ab path; b = −.09, bSE =.04, bCI95%[-.19, −.02]) was found. However, both the total (path c; b = −.16, SE =.12, p = .17, CI95%[-.39,.07]) and direct effects were non-significant (path c’;b = − 0.07, SE = 0.11, p = .55, CI95%[-0.29, 0.15]. According to several authors (Hayes, 2022; Hayes & Rockwood, 2017), the significant total effect is not a requirement of mediation.
Time since diagnosis was a significant predictor for fear of cancer recurrence (a path; b = -2.91, SE = 1.12, p = .01, 95%CI[-5.11, − 0.71]) and fear of cancer recurrence was a significant predictor for trauma centrality (b path; b = 0.03, SE = 0.01, p < .001, CI95%[0.02, 0.04]).
Fig. 1
Statistical model of the mediation analysis of the effect of time since diagnosis on trauma centrality through fear of cancer recurrence. Note. N = 234; **p < .01; ***p < .001
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Moderation Analysis
The overall regression model was significant (F(3, 230) = 12.48, p < .001) and explained 14% (R2 = 0.14) of the variance of trauma centrality. Results showed that cancer stage at diagnosis significantly moderated the relationship between fear of cancer recurrence and trauma centrality (b = − 0.03, SE = 0.01, p = .035, CI95%[-0.05, − 0.002], ΔR = 0.02).
Conditional effects analysis (Fig. 2) for mean and − 1/+1SD showed that the effect was stronger for early stage (b = 0.045, SE = 0.009, p < .001, CI95% [0.03, 0.06]) compared with late-stage (b = 0.02, SE = 0.009, p = .05, CI95%[0.000, 0.04]). Stated differently, greater FCR indicates a greater trauma centrality for early-stage cancer survivors, but not for late-stage survivors.
Fig. 2
Interaction effect of Fear of cancer recurrence and stage at cancer diagnosis on trauma centrality
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Moderated Mediation Analysis
We tested whether the indirect effect indicated by the mediation analysis (Fig. 2) was influenced by the cancer stage at diagnosis (Fig. 3). A percentile bootstrapp with 5,000 samples was used to indicate the indirect effects. The second-order moderated mediation model was tested using PROCESS for IBM SPSS (Hayes, 2022), model 14.
Fig. 3
The moderated mediation conceptual model (Model 14, Process, Hayes, 2022). Note. N = 234; *p < .05; **p < .01; ***p < .001, FCR = Fear of Cancer Recurrence
×
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The index of moderated mediation (Hayes, 2015) showed that the stage at diagnosis moderated the indirect effect of time since diagnosis on trauma centrality through fear of cancer recurrence (b = 0.08, bSE = 0.05, bCI95%[0.002, 0.20]). Conditional indirect effects analysis showed a stronger indirect effect for the early stage at diagnosis (b = − 0.13, bSE = 0.06, bCI95%[-0.27, − 0.03]) than for the late stage at diagnosis (b = − 0.05, bSE = 0.03, bCI95%[-0.12, − 0.001]).
Discussions
Previous research suggests that time since diagnosis, fear of cancer recurrence (FCR), and trauma centrality play crucial roles in shaping the experience of cancer survivorship and mental health (Cook et al., 2021; Koch et al., 2013; Morris et al., 2011; Podina et al., 2023a). However, studies investigating the relationship between these variables are rare. While the relationship between FCR and trauma centrality is essential for understanding the psychological impact on cancer survivors, there has been limited in-depth examination of these variables, especially in relation to time since diagnosis and different cancer stages. The present study addresses this salient gap by pursuing a twofold objective from a cognitive-behavioral standpoint using a moderated mediation model that interchanges these variables.
The main findings are discussed below.
Mediation
As hypothesized, FCR was a significant mediator between time since diagnosis and trauma centrality, resulting in a total mediation that explained approximately 10% of the variance in trauma centrality. This finding aligns with previous research that has established a relationship between FCR and trauma centrality (Black & White, 2005; Curran et al., 2020), although often in less direct terms. The impact of FCR on trauma centrality can be comprehended by examining how individuals’ fear of recurrence affects their assessment of cancer’s importance to their identity. This perspective is grounded in the cognitive-behavioral theoretical framework proposed by Beck in 1976.
In our study, mediation analysis found time since diagnosis significantly predicted FCR, which in turn significantly predicted trauma centrality. This suggests that as time since diagnosis increases, survivors’ fears of cancer recurrence play a critical role in how the cancer experience becomes central to their identity. While the direct effect of time since diagnosis on trauma centrality is not significant, the mediation analysis indicates that the path via FCR is significant. Of course, this finding aligns with the principles of mediation, which assert that a significant overall effect is not a necessary condition for mediation (Hayes, 2015; Hayes & Rockwood, 2017). The negative relationship between the time of diagnosis and FCR indicates that as the time of diagnosis increases, FCR decreases. According to Lebel et al. (2012) and Séguin Leclair et al. (2019), this may be explained by the gradual decrease in fear among survivors as time passes without experiencing a relapse. It suggests that a positive relationship between FCR and trauma centrality means that individuals who consistently experience high levels of FCR are more vulnerable to viewing cancer as a key feature of their identity and, by implication, lower quality of life (Tran et al., 2022).
Moderated Mediation Analysis
After including the stage of diagnosis as a potential moderator, the moderated mediation analysis indicated significant conditional indirect effects of time since diagnosis on trauma centrality via FCR, which were moderated by cancer stage. For early-stage cancer survivors, the indirect effect was stronger, showing that the time after diagnosis had a greater impact on their perception of disease as important to their identity due to increasing FCR. Early-stage survivors with a higher FCR may engage in ongoing health monitoring and lifestyle adjustments to prevent recurrence, which keeps the memory and impact of their diagnosis at the forefront of their minds.
In contrast, for late-stage survivors, the mediated effect was reduced, implying a smaller influence. Although they continue to feel worried about the potential recurrence of the cancer, it does not significantly influence their overall self-perception. Individuals diagnosed at an advanced stage might demonstrate a lower relationship between FCR and trauma centrality due to their major psychological focus shifting towards the fear of death rather than recurrence.
This finding is in line with previous studies showing that individuals with higher vulnerability to certain psychological triggers, such as fear of recurrence, tend to experience more profound psychological impacts (Hall et al., 2019; Ozakinci et al., 2014). Our results indicated that the link between time since diagnosis and trauma centrality, mediated by FCR, leads to varying levels of trauma centrality, with this effect being stronger or weaker depending on the cancer stage at diagnosis.
Other Results
Although the overall diference was not- significant, the results suggested a a small difference among cancer survivors of the early stage, who reported significantly lower trauma centrality compared to the ones in the late stage. This could suggest that individuals who receive a cancer diagnosis with an earlier stage of the disease may perceive their cancer experience as less central to their identity. Many reasons may account for this finding, but the most probable is the fact that early-stage survivors get their treatments more promptly, for a shorter duration, and less invasive (Sciotto et al., 2017). Because of this, the cancer diagnosis is integrated into their lives, and the depth of settlement within their self-concept is not as intense, hence lesser psychological distress with less impact of cancer on the self-concept.
A relevant result shows similar levels of FCR, suggesting that psychological responses to cancer are multifaceted. The absence of a significant difference in FCR between early and late-stage cancer survivors highlights that the fear of cancer returning is a shared experience that transcends differences in prognosis awareness (Curran et al., 2017).
Further interesting outcome was presented: short-term survivors experience higher anxiety and uncertainty about their future health than long-term survivors. This is consistent with previous studies showing that long-term survivors may have adapted to their survivorship status over time, resulting in lower levels of FCR (Götze et al., 2019; Podina et al., 2023b; Séguin Leclair et al. 2019).
Limitations and Future Directions
While our study provides valuable information, it has limitations. The cross-sectional design precludes the ability to establish causal inferences about the relationships between variables. Longitudinal studies are essential to gain a deeper understanding of the temporal dynamics and causality of these links.
In addition, the small sample size may limit the generalizability of our findings to a broader group of cancer survivors. A future study should aim to include larger and more diverse samples to enhance the robustness and applicability of the findings.
Furthermore, the absence of male involvement emphasizes the importance of achieving gender equality in order to fully understand FCR’s gender-related components. Future research endeavors should strive to have a more balanced gender distribution in order to comprehensively examine any gender discrepancies.
Another notable constraint is that our study did not examine the ultimate element of the ABC cognitive paradigm, which encompasses behaviors and emotions (C). This exclusion leads to an inadequate comprehension of the cyclical mechanism by which FCR impacts individuals’ reactions and coping strategies. Subsequent investigations should analyze the complete ABC model in order to gain a more comprehensive understanding of the interplay between beliefs (B1 and B2) and behaviors/emotions (C), and their impact on outcomes such as emotional well-being, specific behavioral consequences, and overall quality of life among those who have survived cancer.
Besides that, our research did not specifically analyze the fear of death, which is a notable cause of stress and anxiety among those who have survived cancer. Future research should examine dread of mortality as a separate factor from FCR in order to have a more comprehensive comprehension of the emotional and psychological requirements of those who have survived cancer.
Moreover, the study participants were primarily of a younger age group, with an average age of approximately 35 years. This may restrict the generalizability of the findings to all demographics of cancer survivors. Subsequent investigations should encompass a broader spectrum of age groups in order to ascertain the applicability of the results across different age cohorts.
Additionally, the study’s particular emphasis on specific forms of cancer and the uneven distribution of patients throughout different stages of cancer may restrict its applicability. To accurately capture the varying experiences of cancer survivors, future research should strive for a more equitable representation of various cancer kinds and stages, considering the heterogeneous character of the disease. While we attempted to mitigate this constraint by presenting the bootstrapped outcomes for the index of moderated mediation, future investigations should aim for more equitable distributions.
Our mediation model only accounts for a small proportion of the total variation in trauma centrality. Although this is useful, there may be other undiscovered elements that also have significant roles. Further investigation is warranted to examine other variables that may impact the importance of trauma in cancer survivors, in order to prevent drawing excessive conclusions only based on the existing model.
Conclusions
Our work shows that the time since diagnosis, the FCR, and the stage of cancer at diagnosis all play complex roles in determining how trauma-centered cancer survivors are. Early-stage survivors have a stronger link between FCR and trauma centrality, even though they have less trauma centrality overall. This suggests that FCR has a stronger psychological effect on these survivors. This demonstrates the need to specifically address FCR in psychological treatment, particularly for early-stage survivors, to prevent trauma from significantly consuming their lives.
Finally, our research shows how important it is to use a cognitive-behavioral approach to understand how time since diagnosis, FCR and cancer stage affect trauma centrality in a moderated way. By including these factors, we can create more complex and useful psychological treatments that are better suited to the unique needs of cancer survivors, ultimately improving their mental health and quality of life.
Acknowledgements
We would like to express our sincere gratitude to all the participants who generously shared their experiences and contributed to this study.
Declarations
Animal Rights
No animal studies were carried out by the authors for this article.
Informed Consent
Informed consent was obtained from all individual participants included in the study.
Conflict of Interest
The Authors declare that there is no conflict of interest.
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