Restricted accessResearch articleFirst published online 2026-3
A qualitative examination of cognitive behavioral therapy strategies and health management content to reduce fear of cancer recurrence among breast cancer survivors: Results from the FoRtitude study
Fear of recurrence (FoR) is common among breast cancer survivors (BCS). We sought to understand BCS’ cognitive behavioral therapy (CBT) and health management content (HMC) intervention component experiences, to aid interpretation of previous findings, and inform future research. HMC comprised health-related content, including managing comorbidities and nutritional information. BCS with elevated FoR were randomized to CBT components (vs HMC) over 4 weeks. Post-participation interviews and additional data from FoRtitude BCS (N = 101) were analyzed. BCS were on average 55 years old (range 26–76 years), White (96%), non-Hispanic (93%), and diagnosed with early-stage breast cancer (87%). Analysis identified four themes: increased self-efficacy, including immediate access and interaction, managing emotional arousal, managing perceived risk of recurrence, and opportunities for future FoRtitude refinements. CBT and HMC play mechanistically distinct yet complementary roles in reducing FoR through increased self-efficacy supported by emotion- and problem-focused coping. Combining such content may be advantageous for reducing BCS’ FoR.
ArmesJCroweMColbourneL, et al. (2009) Patients’ supportive care needs beyond the end of cancer treatment: a prospective, longitudinal survey. Journal of Clinical Oncology27(36): 6172–6179.
2.
BártoloAPachecoERodriguesF, et al. (2019) Effectiveness of psycho-educational interventions with telecommunication technologies on emotional distress and quality of life of adult cancer patients: A systematic review. Disability and Rehabilitation41(8): 870–878.
3.
ClarkLTWatkinsLPiñaIL, et al. (2019) Increasing diversity in clinical trials: Overcoming Critical Barriers. Current Problems in Cardiology44(5): 148–172.
4.
CollinsLMDziakJJKuglerKC, et al. (2014) Factorial experiments: efficient tools for evaluation of intervention components. American Journal of Preventive Medicine47(4): 498–504.
5.
CollinsLMMurphySANairVN, et al. (2005) A strategy for optimizing and evaluating behavioral interventions. Annals of Behavioral Medicine30(1): 65–73.
6.
DilworthSHigginsIParkerV, et al. (2014) Patient and health professional’s perceived barriers to the delivery of psychosocial care to adults with cancer: A systematic review. Psycho-oncology23(6): 601–612.
7.
DorvalMMaunsellEDeschênesL, et al. (1998) Long-term quality of life after breast cancer: Comparison of 8-year survivors with population controls. Journal of Clinical Oncology16(2): 487–494.
8.
EllegaardMBBGrauCZachariaeR, et al. (2017) Fear of cancer recurrence and unmet needs among breast cancer survivors in the first five years. A cross-sectional study. Acta Oncologica56(2): 314–320.
9.
HallDLLevineBJJeterE, et al. (2022) A spotlight on avoidance coping to manage fear of recurrence among breast cancer survivors in an eHealth intervention. Journal of Behavioral Medicine45(5): 771–781.
10.
HallDLWagnerLILebelS, et al. (2024) Guidelines needed for the management of fear of cancer recurrence in adult survivors of cancer in the United States: A consensus statement. Cancer130: 2739–2742. Epub ahead of print 20240417. DOI: 10.1002/cncr.35326
11.
HawkinsNASmithTZhaoL, et al. (2010) Health-related behavior change after cancer: Results of the American cancer society’s studies of cancer survivors (SCS). Journal of Cancer Survivorship4(1): 20–32.
12.
Institute of Medicine (US) Committee on Psychosocial Services to Cancer Patients/Families in a Community Setting (2008) Cancer Care for the Whole Patient: Meeting Psychosocial Health Needs. In: AdlerNEPageAEK (eds)Washington, DC: National Academies Press (US).
13.
JimenezDEBegleyABartelsSJ, et al. (2015) Improving health-related quality of life in older African American and non-Latino White patients. American Journal of Geriatric Psychiatry23(6): 548–558.
14.
KanJMDiengMButowPN, et al. (2021) Identifying the ’Active Ingredients’ of an effective psychological intervention to reduce fear of cancer recurrence: A process evaluation. Frontiers in Psychology12: 661190.
15.
LebelSMaheuCTomeiC, et al. (2022) Mechanisms of change of a cognitive-existential group intervention for fear of cancer recurrence: Mediation analyses of the FORT trial. Journal of Psychosocial Oncology Research and Practice4(3): 2637–5974.
16.
LebelSOzakinciGHumphrisG, et al. (2016) From normal response to clinical problem: Definition and clinical features of fear of cancer recurrence. Supportive Care in Cancer24(8): 3265–3268.
17.
Lee-JonesCHumphrisGDixonR, et al. (1997) Fear of cancer recurrence—A literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psycho-Oncology6(2): 95–105.
18.
LeventhalHLeventhalEAContradaRJ (1998) Self-regulation, health, and behavior: A perceptual-cognitive approach. Psychology and Health13(4): 717–733.
19.
LeykinYThekdiSMShumayDM, et al. (2012) Internet interventions for improving psychological well-being in psycho-oncology: Review and recommendations. Psycho-oncology21(9): 1016–1025.
20.
LucasARPanJHIpEH, et al. (2023) Validation of the Lee-Jones theoretical model of fear of cancer recurrence among breast cancer survivors using a structural equation modeling approach. Psycho-oncology32(2): 256–265.
21.
Luigjes-HuizerYLTauberNMHumphrisG, et al. (2022) What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis. Psycho-oncology31(6): 879–892.
22.
MehnertABergPHenrichG, et al. (2009) Fear of cancer progression and cancer-related intrusive cognitions in breast cancer survivors. Psycho-oncology18(12): 1273–1280.
23.
MeyerDZAveryLM (2009) Excel as a qualitative data analysis tool. Field Methods21(1): 91–112.
24.
MohrDCDuffecyJHoJ, et al. (2013) A randomized controlled trial evaluating a manualized TeleCoaching protocol for improving adherence to a web-based intervention for the treatment of depression. PLoS One8(8): e70086.
25.
NicholasDR (2015) Psychosocial Care of the Adult Cancer Patient: Evidence-Based Practice in Psycho-Oncology. New York: Oxford University Press.
26.
Ochoa-ArnedoCMedinaJCFlix-ValleA, et al. (2021) E-health ecosystem with integrated and stepped psychosocial services for breast cancer survivors: Study protocol of a multicentre randomised controlled trial. BMJ Open11(3): e041548.
27.
ReynoldsCf3rdThomasSBMorseJQ, et al. (2014) Early intervention to preempt major depression among older black and white adults. Psychiatric Services65(6): 765–773.
28.
SaldañaJ (2021) The coding manual for qualitative researchers. The coding manual for qualitative researchers. 1-440.
29.
SimardSSavardJIversH (2010) Fear of cancer recurrence: specific profiles and nature of intrusive thoughts. Journal of Cancer Survivorship4(4): 361–371.
30.
TauberNMO’TooleMSDinkelA, et al. (2019) Effect of psychological intervention on fear of cancer recurrence: A systematic review and meta-analysis. Journal of Clinical Oncology37(31): 2899–2915.
31.
TomeiCLebelSMaheuC, et al. (2016) Addressing fear of recurrence: improving psychological care in cancer survivors. Supportive Care in Cancer24(7): 2815–2818.
32.
TracySJ (2019) Qualitative Research Methods: Collecting Evidence, Crafting Analysis, Communicating Impact. Newark: John Wiley & Sons.
33.
van Den Beuken-van EverdingenMHJPetersMLde RijkeJM, et al. (2008) Concerns of former breast cancer patients about disease recurrence: A validation and prevalence study. Psycho-Oncology: Journal of the Psychological, Social and Behavioral Dimensions of Cancer17(11): 1137–1145.
34.
WagnerLIDuffecyJBegaleM, et al. (2020) Development and refinement of FoRtitude: An eHealth intervention to reduce fear of recurrence among breast cancer survivors. Psycho-oncology29(1): 227–231.
35.
WagnerLIDuffecyJPenedoF, et al. (2017) Coping strategies tailored to the management of fear of recurrence and adaptation for E-health delivery: The FoRtitude intervention. Cancer123(6): 906–910.
36.
WagnerLIToozeJAHallDL, et al. (2021) Targeted eHealth intervention to reduce breast cancer survivors’ fear of recurrence: Results from the FoRtitude Randomized Trial. Journal of the National Cancer Institute113(11): 1495–1505.
37.
ZoberiKTuckerJ (2019) Primary Care of breast cancer survivors. American Family Physician99(6): 370–375.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
