The Journal of Nursing Research h VOL. 24, NO.

3, SEPTEMBER 2016 ORIGINAL ARTICLE

Fear of Cancer Recurrence and Its Impacts on

Quality of Life in Family Caregivers of
Patients With Head and Neck Cancers
Ching-Rong Lin1 & Shu-Ching Chen2 & Joseph Tung-Chien Chang3 & Yuan-Yuan Fang4
Yeur-Hur Lai5*

1
PhD, RN, Instructor, Department of Nursing, College of Medicine, Chang Gung University & 2PhD, RN, Associate Professor,
Department of Nursing, Chang Gung University of Science and Technology & 3MD, MHA, Attending Physician,
Departments of Radiation Oncology, Chang Gung Medical Foundation, Chang Gung Memorial Hospital,
and Professor, Department of Medicine, College of Medicine, Chang Gung University & 4MSN, RN,
Doctoral Student, School of Nursing, College of Medicine, National Taiwan University &
5
PhD, RN, Professor, School of Nursing, College of Medicine,
National Taiwan University.

appropriate support. Future research should develop and exam-

ABSTRACT
Background: Fear of cancer recurrence (FCR) is a major concern
for family caregivers (FCs) caring for patients with head and neck
cancers (HNCs).
Purpose: This study (a) investigated the FCR experience of
HNC FCs, (b) compared the differences in the FCR levels of FCs
while taking care of patients with different lengths of time since
completing major treatments (posttreatment durations), and (c)
examined the correlation between FCR and quality of life (QOL)
in these FCs.
Methods: A cross-sectional study was conducted in the radiation
outpatient department of a medical center in northern Taiwan. A
set of questionnaires, including the Fear of Cancer Recurrence
Inventory-Caregiver version and the Medical Outcomes Short-
Form Health Survey, and a background information form were
employed. One-way analysis of variance was used to examine
the differences in the FCR and QOL among groups of FCs taking
care of patients with different posttreatment durations (typically
concurrent chemoradiotherapy). Pearson’s correlation was used
to identify the relationship between FCR and QOL.
Results: Two hundred fifty FCs were recruited in this study. The
FCs used several coping and reassurance strategies to address
their FCR experiences. Those FCs who cared for patients with
short posttreatment durations (3Y6 and 6Y12 months) showed
significantly higher overall FCR levels and higher FCR severity
levels than those who cared for patients with long posttreatment
durations (more than 5 years). High FCR was negatively correlated
with physical and mental QOL.
Conclusions/Implications for Practice: The results suggest
that FCs caring for patients with a relatively short posttreatment
duration experience higher levels of FCR than those caring for
patients with a longer posttreatment duration. In clinical settings,
healthcare providers should use posttreatment duration as an
indicator of risk of FCR in caregivers to address FCR and provide
ine interventions to help HNC FCs cope effectively with their FCR
and improve their QOL.
KEY WORDS:
cancer, caregiver, fear of cancer recurrence (FCR), quality of
life (QOL).
Introduction
Head and neck cancers (HNCs) are cancers in the oral cavity,
pharynx, and larynx (Weiss & Hayes, 2014). HNCs are
the sixth leading cause of cancer worldwide (Rousseau &
Badoual, 2012). In Taiwan, approximately 6,890 new HNC
cases are reported per year (Taiwan Cancer Registry, 2015).
The 5-year survival rate of patients with HNCs is approxi-
mately 40%Y50% (Rousseau & Badoual, 2012). HNCs have
a higher recurrence rate compared with other types of cancer
(Rassouli, Saliba, Castano, Hier, & Zeitouni, 2015).
Family caregivers (FCs) play critical roles in supporting
patients with treatments through the survival period (Clayton
et al., 2007; Kim, Kashy, Spillers, & Evans, 2010). However,
Accepted for publication: October 6, 2015
*Address correspondence to: Yeur-Hur Lai, No.1, Sec.1, Jen-Ai Rd.,
Zhongzheng District, Taipei City 10051, Taiwan, ROC.
Tel: +886(2)23123456 ext. 88429; E-mail: laiyhwk@ntu.edu.tw
The authors declare no conflicts of interest.
Cite this article as:
Lin, C. R., Chen, S. C., Chang, J. T. C., Fang, Y. Y., & Lai, Y. H.
(2016). Fear of cancer recurrence and its impacts on quality of life
in family caregivers of patients with head and neck cancers.
The Journal of Nursing Research, 24(3), 240Y248. doi:10.1097/
jnr.0000000000000169

240

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Cancer Recurrence Fear in HNC Caregivers
caregivers, similar to patients, experience the threat of can-
cer recurrence, called the ‘‘fear of cancer recurrence’’ (FCR),
which refers to the degree of concern that subjects report re-
garding the chances of cancer returning in the future (Hodges
& Humphris, 2009).
FCR is one of the most critical concerns in cancer survi-
vorship (Stanton, Rowland, & Ganz, 2015). Previous studies
have indicated a significant relationship between the FCR
of patients and that of their caregivers (Mellon, Kershaw,
Northouse, & Freeman-Gibb, 2007). FCR may affect the abil-
ity of FCs to provide care and influence their quality of life
(QOL; Hodges & Humphris, 2009; Matthews, 2003). Some
studies have revealed that FCs report higher FCR concerns
than their patients (Hodges & Humphris, 2009; Mellon
et al., 2007). A high FCR in caregivers has been associated
with cancer-related anxiety (Matthews, 2003) and has been
implicated in increased psychiatric morbidity such as anxiety
disorders (Drabe et al., 2008). However, most recent studies
have focused on the FCR of patients (Crist & Grunfeld, 2013),
and few have investigated the FCR of caregivers.
Prior studies have suggested that level of FCR may be re-
lated to the posttreatment survival time of the patient (Dunn
et al., 2015; Hodges & Humphris, 2009; Humphris et al.,
2003; Liu et al., 2011; Longacre, Ridge, Burtness, Galloway,
& Fang, 2012). Humphris et al. (2003) showed that patients
reported higher levels of cancer recurrence at 3 months post-
treatment than at 7 months posttreatment. Liu et al. (2011)
reported a similar finding, indicating that the FCR of pa-
tients with breast cancer decreased significantly from 6 weeks
to 2 years postsurgery. Dunn et al. (2015) revealed that FCR
was higher in patients with breast cancer who received anti-
cancer surgery within 6 months compared with those who
received cancer surgery after a longer duration and that FCR
decreased over time. A previous study showed that the FCR
of patients with HNC and that of their caregivers were
significantly correlated with psychological distress at 3 and
6 months after treatment (Hodges & Humphris, 2009).
Longacre et al. (2012) found that the 6-month interval after
diagnosis is a critical period in which the caregivers of pa-
tients with HNC are concerned about cancer recurrence.
For patients with HNC, FCR contributes to functional
impairment and mental instability (Handschel, Naujoks,
Kübler, & Krüskemper, 2012). Another study found that
high levels of fear in patients relate to their levels of psycho-
logical distress, functional impairments, difficulty in making
plans (Custers et al., 2015), and QOL (Kim, Carver, Spillers,
Love-Ghaffari, & Kaw, 2012). Moreover, caregivers have
reported that high levels of FCR are related to the poor
physical health of patients (Kim et al., 2012).
On the basis of a review of the literature, we assumed that
FCs experience different levels of FCR during survival care-
giving 2007; Vivar, Canga, Canga, & Arantzamendi, 2009).
Survival time (Dunn et al., 2015; Herschbach et al., 2010;
Longacre et al., 2012) and QOL (Custers et al., 2015;
Handschel, Naujoks, Hofer, & Krüskemper, 2013; Kim et al.,
2012) are negatively correlated with FCR. To address these
Copyright © 2016 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 24, NO. 3, SEPTEMBER 2016
gaps in knowledge, this study (a) investigated the FCR ex-
perience of HNC FCs, (b) compared the differences in the
FCR levels of FCs taking care of patients with different lengths
of time since completing major cancer treatment (posttreat-
ment durations), and (c) examined the correlation between
FCR and QOL in these FCs.
Methods
Research Design and Participants
A cross-sectional survey with convenience sampling was
used to examine the experience of FCR and its effect on the
QOL of FCs. Participants were recruited from the HNC out-
patient radiation department of a medical center in northern
Taiwan. FCs were included according to the following in-
clusion criteria: (a) aged 18 years or older, (b) provided reg-
ular primary care to a patient with HNC who had completed
treatment for more than 3 months and was without any fur-
ther signs or symptoms of HNC, (3) able to speak and read
Mandarin or Taiwanese, and (4) agreed to participate in this
study after being informed of its purposes.
Ethical Consideration and Data
Collection Procedures
The institutional review board of the Human Subject Com-
mittee approved this study (IRB no. CGMH102-2393C). All
of the participants signed consent forms after receiving a com-
prehensive explanation of the research purposes. Trained re-
search assistants interviewed the participants by using structured
questionnaires before visiting the outpatients. The interviews
lasted approximately 10Y15 minutes.
Statistical power analysis for correlation was used to de-
termine that a minimum sample size of 220 participants was
necessary to achieve a power of 0.85 with a significance level
(alpha) of .05 (VanVoorhis & Morgan, 2007).
Measurements
Fear of cancer recurrence inventory-caregiver
version
The 42-item Fear of Cancer Recurrence Inventory-Caregiver
version (FCRI-c), an instrument that is used to measure the
FCR of caregivers, was modified from the FCRI-Patient
version (Simard & Savard, 2009), which in turn was devel-
oped using the cognitiveYbehavioral formulation (Lee-Jones,
Humphris, Dixon, & Hatcher, 1997). The FCRI was eval-
uated by experts as having favorable validity and reliability
(Simard & Savard, 2009). The FCRI-c has seven subscales:
triggers (eight items), severity (nine items), psychological dis-
tress (four items), functional impairment (six items), insight
(three items), reassurance (three items), and coping strategy
(nine items). For each item, the score ranges from 0 = not at
all/ never to 4 = a great deal/all the time. A high score in-
dicates high levels of FCR (Simard & Savard, 2009). The
Cronbach’s ! of the original-version FCRI was .95. The
Cronbach’s ! value for the FCRI-c in this study was .94.
241
The Journal of Nursing Research Ching-Rong Lin et al.

The medical outcomes short-form health survey unemployed (58.8%) and had religious beliefs (80.0%). Most
The Medical Outcomes Short-Form Health Survey (SF-12) of the patients were men (82.4%), diagnosed with nasopharynx
was used to assess health-related QOL. The 36-item SF-12 (43.6%) and Stage III or IV (66.8%), treated with concurrent
has two subscales: physical composite score and mental com- chemoradiotherapy (46.4%), and without metastasis (83.6%).
posite score. Scores are transformed to 0Y100, with high The average posttreatment duration was 46.3 months (SD =
scores indicating a high level of QOL. Acceptable psycho- 52.9 months; Table 1).
metric properties were reported for this survey in previous
research (Lu, Tseng, & Tsai, 2003). The Cronbach’s ! value
for the SF-12 in this study was .79. TABLE 1.
Demographic and Clinical
Background information form Characteristics (N = 250)
The background information on FCs that was collected for
this study included age, gender, educational level, employ- Variable n % Range
ment status, religion, and relationship to the patient. We
collected data on the age, gender, cancer site, cancer stage, Family caregivers
Age (years; M, SD) (47.4, 12.2) 18Y74
treatment types, metastasis, and posttreatment duration
Gender
(months) of the patients.
Female 205 82.0
Male 45 18.0
Educational level
Statistical Analysis Junior high school 94 37.6
Descriptive statistics (frequency, percentage, means, and and below
standard deviations) were used to analyze demographic and Senior high and 85 34.0
clinical characteristics as well as the FCR experience of the vocational school
FCs. All of the collected data were subjected to a one-way College, university, 71 28.4
analysis of variance (Cardinal & Aitken, 2013); the data and above
showed a normal distribution and homogeneity of variances Employment
Unemployed 147 58.8
without outliers (KolmogorovYSmirnov Z test: FCR, p =
Employed 103 41.2
.655; physical QOL, p = .083; mental, p = .293). Analysis
Religion
of variance with post hoc analysis was performed to ex- No 50 20.0
amine the levels of overall FCR, FCR subscales, and QOL Yes 200 80.0
(including physical and mental composite) among the FCs Relation with survivors
who were taking care of patients with different posttreat- Nonspouse 76 30.4
ment durations (typically concurrent chemoradiotherapy). Spouse 174 69.6
We divided the patients into five groups according to their Patients
posttreatment durations: 3Y6 months (Group A), 96 months Age (years; M, SD) (54.4, 10.7) 22Y82
but e12 months (Group B), 912 months but e3 years (Group Gender
C), 93 years but e5 years (Group D), and 95 years (Group E). Female 44 17.6
The dependent variable (FCR) and independent variables Male 206 82.4
(physical composite QOL and mental composite QOL) Tumor site
were continuous and exhibited a linear relationship with no Nasopharynx 109 43.6
Pharyngeal + larynx 55 22.0
significant outliers. Furthermore, these variables were
Oral cavity 75 30.0
approximately normally distributed according to the as-
Others 11 4.4
sumption of the Pearson productYmoment correlation Cancer stage
coefficient (Rovai, Baker, & Ponton, 2013). The Pearson I + II 83 33.2
productYmoment correlation was used to identify the cor- III + IV 167 66.8
relation of FCR and QOL. A p value less than .05 was Treatment type
considered statistically significant. RT only 22 8.8
CCRT only 116 46.4
Surgery + RT 29 11.6
Surgery + CCRT 83 33.2
Results Metastasis
No 209 83.6
Participant Characteristics Yes 41 16.4
Posttreatment duration (46.3, 52.9)
Two hundred fifty FCs were recruited in this study. The mean
(months; M, SD)
age was 47.4 years (SD = 12.2 years, range = 18Y74 years).
Most of the FCs were female (82.0%), married (69.6%), and Note. RT = radiotherapy; CCRT = concurrent chemoradiotherapy.

242

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Cancer Recurrence Fear in HNC Caregivers
Current Status of Fear of Cancer
Recurrence in Family Caregivers of
Patients With Head and Neck Cancers
The FCs used several coping and reassurance strategies in their
FCR experiences. To clearly understand the FCR experi-
ence of FCs, we calculated the mean scores (SD) for each
item and then ranked these items from highest to lowest.
Regarding the trigger subscale, more than 50% of the FCs
rarely or sometimes perceived a trigger of FCR. Regarding the
reassurance subscale, most of the FCs reported that they
sometimes or most of the time required reassurance regarding
their FCR. Regarding the coping strategy, more than half of the
FCs used multiple coping strategies for FCR sometimes or
most of the time. Regarding the severity subscale, approxi-
mately half of the FCs perceived the level of severity of FCR as
a little or somewhat. Regarding the psychological distress
subscale, most of the FCs perceived the level of psychological
distress from FCR as a little or somewhat. Regarding the
functional impairment subscale, nearly two thirds of the FCs
perceived the level of functional impairment of FCR as a lit-
tle or somewhat. Regarding the insight subscale, more than
two thirds of the FCs had a little or somewhat insight of
FCR (Table 2).
Differences Between the Fear of Cancer
Recurrence Levels and Quality of Life in
Family Caregivers Caring for Patients
With Head and Neck Cancers of Different
Posttreatment Durations
In general, for the overall FCR scores, FCs taking care of pa-
tients with posttreatment durations of 3Y6 months and of
more than 6Y12 months experienced a significantly higher
overall FCR score than those taking care of patients with
a posttreatment duration of more than 5 years. FCs taking
care of patients with posttreatment durations of 3Y6 months
showed the highest level of FCR severity (severity subscale),
which was also significantly higher than that of those taking
care of patients with posttreatment durations of more than
3Y5 years and of more than 5 years. FCs taking care of pa-
tients with posttreatment durations of 3Y6 months exhibited
the lowest mental-health-related QOL, which approached
statistical significance (Table 3).
Relationship Between Fear of Cancer
Recurrence and the Quality of Life
of Family Caregivers
Several critical correlations of physical and mental composite
QOL were determined. FCs with higher levels of FCR severity
and insight about cancer recurrence were likely to experience
a lower physical QOL (r = j.19 and j.15, respectively).
Moreover, FCs with a high overall FCR, high trigger levels,
high FCR severity, high psychological distress related to FCR,
high functional impairment related to FCR, and high insight
Copyright © 2016 Taiwan Nurses Association. Unauthorized reproduction of this article is prohibited.
VOL. 24, NO. 3, SEPTEMBER 2016
about cancer recurrences reported relatively poor mental com-
posite QOL scores, respectively (r = j.34, j.21, j.32, j.36,
j.38, and j.36, respectively; Table 4).
Discussion
The FCs in this study identified coping strategy as the sub-
scale that yielded the highest level of FCR and that involved
the most items among the top ranking FCR. This finding is
inconsistent with previous studies and may be because of
the patients in this study having longer posttreatment du-
rations than patients in previous studies (Mellon et al., 2007;
Vivar et al., 2009). Most of the FCs were the primary care-
givers and performed intense caregiving tasks from acute
treatment to survival. Thus, caregiving stressors may be a
particular challenge for the FCs of patients with HNCs. FCs
must manage a range of side effects for patients and the
cumulative caregiving experience to improve their coping
abilities. Our study revealed that FCs experienced multi-
faceted FCR, particularly with regard to coping strategies. In
clinical care, transitional care is required to enhance knowl-
edge and skill in coping with HNC-related concerns at home.
In our study, ‘‘going with him or her to the hospital or
clinic for an examination’’ and ‘‘examining whether he or she
has any physical signs of cancer’’ were items that related prom-
inently to FCR in FCs of patients with HNCs. This finding
suggests that FCs acquire reassurance regarding recurrence
through their patients’ physical symptom (Lin, Lin, & Lin,
2015; Taylor, Richardson, & Cowley, 2011). Our results
confirmed that, in clinical settings, healthcare providers may
alleviate the FCR of FCs by addressing their concerns. Home-
based interventions may include assisting caregivers in asses-
sing and managing the symptoms of patients with different
posttreatment durations. Other resources may focus on facil-
itating the information needs of FCs through information
consulting and health education because of their patients’ po-
tential recurrence-related symptoms.
In this study, the posttreatment durations of patients sig-
nificantly affected FCs’ FCR and QOL levels. Consistent with
the findings of previous studies (Dunn et al., 2015; Hersch-
bach et al., 2010; Longacre et al., 2012), we observed that
FCs who were taking care of patients with posttreatment
durations of 3Y6 months had higher severity and overall
FCR than their peers who were taking care of patients with
posttreatment durations of more than 5 years. The patients
who had completed their active treatment only recently con-
tinued to experience physical and emotional problems, and
FCs may conflate these problems with recurrence. Our results
confirmed time (duration after treatment) as an important is-
sue for clinically assessing the FCR of FCs to better support
HNC caregivers. As FCR may be induced by unexplained
symptoms, healthcare providers should educate FCs on dif-
ferentiating between the side effects of treatment and the signs
of cancer recurrence.
Examining the correlation between FCR and QOL re-
vealed that FCs with high levels of FCR severity and insight
243
The Journal of Nursing Research Ching-Rong Lin et al.

TABLE 2.
Frequency Distribution for the Level of Agreement on Each FCR (FCRI-c) Item
(N = 250)

Frequency of Experience
0 1 2 3 4
Subscale and Item n % n % n % n % n % M SD Rank

Triggers
When he or she feels less well 39 15.6 62 24.8 109 43.6 28 11.2 12 4.8 1.7 1.0 1
physically or when he or she is sick
Television shows or newspaper 44 17.6 65 26.0 114 45.6 19 7.6 8 3.2 1.5 1.0 2
articles about cancer or illness
Physical examination (annual 42 16.8 80 32.0 91 36.4 28 11.2 9 3.6 1.5 1.0 3
checkup, blood tests, x-rays)
Seeing or hearing someone who’s ill 44 17.6 67 26.8 113 45.2 22 8.8 4 1.6 1.5 0.9
To avoid situations or things that 59 23.6 68 27.2 79 31.6 34 13.6 10 4.0 1.5 1.1
make to think about PCR
Conversations about cancer or illness 45 18.0 74 29.6 106 42.4 20 8.0 5 2.0 1.5 1.0
in general
An appointment with physician or 42 16.8 58 23.2 97 38.8 21 8.4 7 2.8 1.4 1.1
other health professional
Going to a funeral or reading 75 30.0 69 27.6 87 34.8 16 6.4 3 1.2 1.2 1.0
obituary section of the paper
Reassurance
Going with him or her to hospital or 32 12.8 38 15.2 68 27.2 64 12.6 48 19.2 2.2 1.3 1
clinic for an examination
To examine to see if he or she has 41 16.4 46 18.4 77 30.8 52 20.8 34 13.6 2.0 1.3 2
any physical signs of cancer
To call doctor or other health 77 30.8 49 19.6 71 28.4 39 15.6 14 5.6 1.5 1.2 3
professional by my/him/herself
Coping strategy
To convince that everything will be 20 8.0 38 15.2 70 28.0 68 27.2 54 21.6 2.4 1.2 1
fine or think positively
To find a solution 32 12.8 31 12.4 70 28.0 65 26.0 52 20.8 2.3 1.3 2
To replace this thought with a more 35 14.0 27 10.8 72 28.8 68 27.2 48 19.2 2.3 1.3 3
pleasant one
Telling myself ‘‘stop it’’ 42 16.8 38 15.2 65 26.0 66 26.4 39 15.6 2.1 1.3
To understand what is happening 40 16.0 31 12.4 76 30.4 60 24.0 43 17.2 2.1 1.3
and deal with it
Trying not to think about it, to get 56 22.4 46 18.4 72 28.8 47 18.8 29 11.6 1.8 1.3
the idea out of my mind
Trying to distract myself 55 22.0 43 17.2 78 31.2 55 22.0 19 7.6 1.8 1.2
Pray, meditate, or do relaxation 69 27.6 49 19.6 57 22.8 47 18.8 28 11.2 1.7 1.4
Talking to someone about it 58 23.2 57 22.8 83 33.2 41 16.4 11 4.4 1.6 1.1
Severitya
To believe that he or she is cured 41 16.4 43 17.2 62 24.8 65 26.0 39 15.6 2.1 1.3 1
and the cancer will not come back
To believe it is normal to be worried 31 12.4 57 22.8 77 30.8 38 15.2 47 18.8 2.1 1.3 2
or anxious about the PCR
Being afraid of his or her 37 14.8 68 27.2 86 34.4 37 14.8 22 8.8 1.8 1.1 3
cancer recurrence
Thinking about PCR, triggers 42 16.8 65 26.0 97 38.8 27 10.8 19 7.6 1.7 1.1
unpleasant thoughts or images
Being worried or anxious 40 16.0 73 29.2 90 36.0 33 13.2 14 5.6 1.6 1.1
about the PCR (continues)

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Cancer Recurrence Fear in HNC Caregivers VOL. 24, NO. 3, SEPTEMBER 2016

TABLE 2.
Frequency Distribution for the Level of Agreement on Each FCR (FCRI-c) Item
(N = 250), Continued

Frequency of Experience
0 1 2 3 4
Subscale and Item n % n % n % n % n % M SD Rank

Psychological distress
Worry, fear, or anxiety 21 8.4 79 31.6 83 33.2 39 15.6 28 11.2 1.9 1.1 1
Sadness, discouragement, 40 16.0 72 28.8 72 28.8 39 15.6 27 10.8 1.8 1.2 2
or disappointment
Helplessness or resignation 56 22.4 74 29.6 62 24.8 30 12.0 28 11.2 1.6 1.3 3
Frustration, anger, or outrage 124 49.6 64 25.6 36 14.4 10 4.0 16 6.4 0.9 1.2
Functional impairment
State of mind or my mood 52 20.8 83 33.2 58 23.2 34 13.6 23 9.2 1.6 1.2 1
Quality of life in general 80 32.0 79 32.6 53 21.2 25 10.0 13 5.2 1.3 1.2 2
Social or leisure activities 99 39.6 60 24.0 54 21.6 24 9.6 13 5.2 1.2 1.2 3
(e.g., outings, sports, travel)
Ability to make future plans or set life goals 98 39.2 64 25.6 56 22.4 18 7.2 14 5.6 1.1 1.2
Work or everyday activities 103 41.2 66 26.4 43 17.2 26 10.4 12 4.8 1.1 1.2
Relationship with my partner, 120 48.0 62 24.8 39 15.6 19 7.6 10 4.0 1.0 1.1
my family, or those close to me
Insight
I think that I worry more about 69 27.6 85 34.0 56 22.4 25 10.0 15 6.0 1.3 1.2 1
the PCR than other caregivers
I feel that I worry excessively 92 36.8 85 34.0 47 18.8 19 7.6 7 2.8 1.1 1.1 2
about the PCR
Other people think that I worry 109 43.6 86 34.4 41 16.4 10 4.0 4 1.6 0.9 0.9 3
excessively about the PCR

Note. Five-point Likert-type scale with triggers, reassurance, and coping strategy: 0 = never, 1 = rarely, 2 = sometimes, 3 = most of the time, 4 = all the time;
5-point Likert-type scale with severity, psychological distress, functional impairment, and insight: 0 = not at all, 1 = a little, 2 = somewhat, 3 = a lot of the
time, 4 = a great deal. FCRI-c = Fear of Cancer Recurrence Inventory-Caregiver version; PCR = possibility of cancer recurrence.
a
Because of the different meanings of scoring, four items are not listed, including (a) ‘‘In your opinion, is he/she at risk of cancer recurrence?’’, (b) ‘‘How long have
you been thinking about the PCR?’’, (c) ‘‘How much time per day do you spend thinking about the PCR?’’, and (d) ‘‘How often do you think about the PCR?’’.

TABLE 3.
Differences in the FCR and QOL of FCs Among the Posttreatment Duration
Subgroups (N = 250)

 912 Mo
ffi 3Y6 Mo ffl 96 to e12 to e3 Yr Ð 93 to e5 ð 95 Yr
(n = 31) Mo (n = 33) (n = 90) Yr (n = 38) (n = 58)
Variable Mean SD Mean SD Mean SD Mean SD Mean SD F p Post Hoc

FCR (FCRI-c)
Triggers 13.2 5.1 13.2 6.5 11.9 5.4 10.5 5.5 10.6 6.7 1.95 .102
Severity 16.1 5.5 14.6 7.3 14.3 6.5 11.8 5.0 12.3 6.9 3.02 .018 ffi 9 Ð, ð
Psychological distress 7.1 4.1 6.7 3.8 6.5 4.0 6.2 4.2 5.0 4.0 1.98 .094
Functional impairment 9.0 5.2 7.9 5.8 7.2 6.3 7.8 6.7 5.4 5.7 2.16 .074
Insight 4.2 2.3 3.4 3.0 3.1 2.5 3.3 2.8 2.8 3.1 1.47 .213
Reassurance 5.5 2.8 5.9 3.0 5.3 2.9 5.8 3.4 6.0 3.5 0.49 .746
Coping strategy 20.0 7.8 18.6 7.0 17.5 7.7 18.9 9.9 16.6 9.3 1.09 .365
Overall FCR 75.1 23.8 70.4 25.1 65.8 23.6 64.4 26.6 58.7 27.8 2.50 .043 ffi, ffl 9 ð
QOL (SF-12)
Physical composite 52.0 9.8 47.8 9.4 50.6 7.1 48.1 6.9 50.3 7.0 1.90 .112
Mental composite 44.4 8.8 47.3 8.7 47.8 10.0 47.7 8.1 50.7 10.1 2.34 .052

Note. FCR = fear of cancer recurrence; FCRI-c = Fear of Cancer Recurrence Inventory-Caregiver version; Mo = months; QOL = quality of life; Yr = years.

245

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The Journal of Nursing Research Ching-Rong Lin et al.

TABLE 4. care to patients with HNCs. Coping strategy and reassurance

FCR Correlates Related to QOL (N = 250) were high FCR-related concerns for the FCs. Length of time
after HNC treatment was associated with a reduction in FCR
QOL severity and overall FCR, with the shortest posttreatment
Physical Mental duration showing the highest scores for FCR severity and
Composite Composite overall FCR. The FCs who experienced a high FCR reported
poor physical and mental QOL. The findings suggest that
FCR Pearson r p Pearson r p
healthcare providers in clinical settings should assess and
Triggers j.10 .127 j.21 .001 support FCs to better cope with FCR.
Severity j.15 .020 j.32 G.001
Psychological j.09 .140 j.36 G.001
distress Acknowledgments
Functional j.01 .868 j.38 G.001 This study was supported by a grant from the Chang Gung
impairment Memorial Hospital (CMRPD1C0471), Taiwan. The authors
Insight j.19 .002 j.36 G.001 gratefully acknowledge the contribution of the caregivers who
participated in the study. The authors also thank Wesley
Reassurance .04 .524 j.07 .296
Jantjies, Sorrel Tilley, Yankuba Sanyang, and Jeff Miller for
Coping strategy .05 .420 j.04 .554 assistance with English editing.
Overall FCR j.08 .233 j.34 G.001

Note. FCR = fear of cancer recurrence; QOL = quality of life.

were more likely to show a poor physical QOL compared
with other FCs. FCs with high FCR-related triggers, severity,
psychological distress, functional impairment, insight, and
overall FCR reported a poor mental QOL. These findings
are corroborated in the literature (Custers et al., 2015;
Handschel et al., 2012; Kim et al., 2012; Simard & Savard,
2009), indicating that FCR is a long-term consequence of
disease and treatment with the potential to affect caregiving
tasks and QOL. FCR may be more closely related to trigger
situations (e.g., functioning, psychosocial factors, and pro-
vider factors) than patients’ medical characteristics (e.g., can-
cer type and treatment type). For clinical care, healthcare
providers should actively assess the FCR of FCs and its effect
on their QOL. Future studies should examine the trigger
factors that mediate the effects of FCR and QOL.
Limitations and Recommendations
This study had some limitations. First, this study included a
cross-sectional design that assessed the FCR of FCs who
were caring for patients with HNCs. As FCR is a long-term
concern of FCs, a longitudinal investigation is necessary.
Second, we focused on FCs who were caring for patients
with HNCs, a patient group with complex caregiving sit-
uations. Caregiving experiences are one of the factors that
trigger FCR; therefore, future studies may examine the dif-
ferences in caregiving situations caused by FCR. Finally, we
examined FCR experiences and the effect of these experiences
on the QOL of FCs during survivorship. Future studies should
develop interventions and examine the effect on FCR.
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頭頸癌病人之家屬照顧者害怕癌症復發 The Journal of Nursing Research VOL. 24, NO. 3, SEPTEMBER 2016

頭頸癌病人之家屬照顧者害怕癌症復發及
對其生活品質的影響
林青蓉1　陳淑卿2　張東杰3　方圓媛4　賴裕和5*

1
長庚大學醫學院護理學系講師　2長庚科技大學護理學系副教授　3林口長庚醫院放射腫瘤科
主治醫師兼質子中心主任及長庚大學醫學院醫學系教授　4國立臺灣大學醫學院護理學
研究所博士候選人　5國立臺灣大學醫學院護理學研究所教授兼系所主任

背　景 害怕癌症復發是癌症病患之家屬照顧者主要的關注焦點之一。

目　的 本研究目的為：⑴探討頭頸癌病患之家屬照顧者害怕復發的經驗 ，⑵比較照顧完成癌

症治療後不同期間之病患的家屬照顧者害怕復發的程度差異 ，及⑶探討頭頸癌病患之
家屬照顧者害怕復發與其生活品質的關係。

方　法 本研究採橫斷式研究於北台灣某醫學中心放射腫瘤門診收集資料。研究調查問卷包括：
照顧者害怕癌症復發量表（FCRI-c）、SF-12 健康調查問卷（SF-12）及背景資料表。統計
方法採用變異數（ANOVA）及事後檢定 ，比較完成癌症治療後不同期間之病患的照顧
者害怕復發及生活品質的差異 ，以 Pearson’s 相關分析照顧者害怕復發與生活品質的關
係。

結　果 本研究共收集 250 位照顧者 ，害怕復發的經驗中 ，照顧者採用多種因應策略與再確認方

式來面對復發的擔心。病患完成癌症治療後期間（3 至 6 個月或 及大於 6 至 12 個月）越
短 ，照顧者害怕復發嚴重度及整體性的擔心 ，顯著高於病患已完成癌症治療後期間長
達五年以上的照顧者。照顧者害怕癌症復發與其生理及心理層面的生活品質皆呈顯著負
相關。

結　論 本研究結果顯示 ，相對於完成癌症治療後期間較長之病患的照顧者 ，完成治療後期間

實務應用 較短之病患的家屬照顧者有較高的害怕復發困擾。臨床上 ，健康照護人員可根據癌症
病患完成癌症治療後不同期間 ，察覺照顧者害怕病患癌症復發的情形 ，並提供適時的
關注與適當的支持。建議未來應發展並測試幫助頭頸癌之照顧者有效因應害怕復發困擾
的措施 ，以提升其生活品質的研究。

關鍵詞：癌症、照顧者、害怕癌症復發、生活品質。

接受刊載：104年10月6日
*通訊作者地址：賴裕和　　10051台北市中正區仁愛路一段1號
電話：（02）23123456－88429　　E-mail: laiyhwk@ntu.edu.tw

248

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