A Structural Model Explaining the Effect of Cognitive Emotion Regulation on the Fear of Cancer Recurrence in Breast Cancer Survivors: the Mediating Roles of Illness Perception and Psychological Well-being Emotion regulation of FCR

Sedigheh Hosseini (1), Mahdiee Salehi (2), Mohsen Jadidi (3), Mahdi Aghili (4)
(1) Department of Clinical Psychology, Central Tehran Branch, Islamic Azad University, Tehran, Iran, Iran, Islamic Republic of,
(2) Department of Clinical Psychology, Central Tehran Branch, Islamic Azad University, Tehran, Iran, Iran, Islamic Republic of,
(3) Department of Psychology, Guds City Branch, Islamic Azad University, Guds City, Iran, Iran, Islamic Republic of,
(4) Department of Radiation Oncology, Cancer Research Institute, Imam Khomeini Hospital Complex, Tehran University of Medical Science, Tehran, Iran, Iran, Islamic Republic of


Background: Fear of cancer recurrence (FCR) in cancer patients, including those with breast cancer is a special and highly conscious experience having bearing on emotional, cognitive and behavioral domains. This study examines the effect of cognitive emotion regulation on FCR with the mediation of illness perception and psychological well-being in breast cancer survivors in a structural model.

Methods: The population of this study included all women with breast cancer who were referred to Cancer Institute of Iran for their regular checkups in the spring and summer of 2022. 300 patients were recruited based on convenience sampling. They completed the validated questionnaires online for FCR, cognitive emotion regulation, illness perception and psychological well-being. Data were analyzed by using Pearson's correlation coefficient and structural equation modeling analysis.

Results: The findings indicated the model did fit the data. In addition to the direct effect of adaptive and maladaptive strategies of cognitive emotion regulation on FCR, the indirect effect of adaptive strategies on FCR through psychological well-being (β=0.148, p=0.001) and illness perception (β=0.233, p=0.001) was negative and significant. Furthermore, the indirect effect of maladaptive strategies on FCR through psychological well-being (β=0.109, p=0.001) and illness perception (β=0.212, p=0.001) was positive and significant. Therefore Psychological well-being and illness perception negatively and significantly mediated the effect of adaptive strategies on FCR and positively and significantly mediated the effect of maladaptive strategies on FCR.

Conclusion: Patients who possess adaptive strategies of cognitive emotion regulation, less-threatening perception of illness and higher psychological well-being were exposed less to FCR. Psychological interventions for strengthening these factors in breast cancer survivors are suggested.

Full text article

Generated from XML file


Sung H, Ferlay J, Siegel R L, Laversanne M, Soerjomataram I, Jemal A, et al. Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. Cancer J Clin. 2021; 71(3):209-249. doi:10.3322/caac.21660.

Nafissi N, Khayamzadeh M, Zeinali Z, Pazooki D, Hosseini M, Akbari MS. Epidemiology and Histopathology of Breast Cancer in Iran versus Other Middle Eastern Countries. Middle East J Cancer. 2018; 9(3):243-251. doi:10.30476/mejc.2018.42130.

Martino G, Catalano A, Agostino, R M, Bellone F, Morabito N, Lasco C G, et al. Quality of life and psychological functioning in postmenopausal women undergoing aromatase inhibitor treatment for early breast cancer. plos one. 2021;1-16. doi:10.1371/journal.pone.0230681

Tatyana I B, Svetlana Yu V, Natalya I N. Factors of the Development of Fear of Disease Progression in Patients with Breast Cancer. Macedonian J Med Sci. 2020; 8(E):74-80. doi:10.3889/oamjms.2020.3922.

Vagner I L, Duffecy J, Begaie M, Levine B J, Beaumont J, Duffecy J, et al. Development and refinement of FoRtitude: An eHealth intervention to reduce fear of recurrence (FoR) among breast cancer survivors. Psycho-oncology. 29(1), 227-231. doi: 10.1002/pon.5297.

Gormley M, Knob MT, Vorderstrasse A, Aouizerat B, Hammer M, Fletcher J, et al. Exploring the effects of genomic testing on fear of cancer recurrence among breast cancer survivors. Psycho-oncology. 2021; 30(8):1322-1331. doi:10.1002/pon.5679.

Jianlin L, Simard S, Peh Ch X, Griva K, Mahendran R. Beyond the fear that lingers: The interaction between fear of cancer recurrence and rumination in relation to depression and anxiety symptoms. Sychosom Res. 2018; 111:120-126. doi:10.1016/j.jpsychores.2018.06.004.

Garnefski N, Kraaij V. The Cognitive Emotion Regulation Questionnaire - Psychometric features and prospective relationships with depression and anxiety in adults. European J Psychol Assess. 2007; 23(3):141-149. doi:10.1027/1015-5759.23.3.141.

Guimond J A, Ivers H, Savard J. Is emotion regulation associated with cancer-related psychological symptoms? Psychol Health. 2019; 34(1): 44-63. doi:10.1080/08870446.2018.1514462.

Morris RM, Weinman J, Petrie K J, Horne R, Cameron L, Buick D. The revised Illness Perception Questionnaire (IPQ-R). Psychol Health. 2002; 17(1): 1-16. doi: 10.1080/08870440290001494.

Freeman A L, Janz N K, Katapodi C M, Zikmund-Fisher J B, Northouse L. The relationship between illness representations, risk perception and fear of cancer recurrence in breast cancer survivors. Psycho-oncology. 2017; 26(9): 1270-1277. doi: 10.1002/pon.4143.

Ryff CD. Psychological Well-Being Revisited: Advances in the Science and Practice of Eudaimonia. Psychother Psychosom. 2014; 83(1): 10-28. doi: 10.1159/000353263.

Andrykowsk M, Lykins E, Floyd A. Psychological health in cancer survivors. Seminars in Oncol Nursing. 2008; 24(3): 193- 201. doi: 10.1016/j.soncn.2008.05.007.

Hamzepour Haghigi T, Dousti Y, Mirzaian B, Fakhri M. The effectiveness of group-based cognitive behavioral therapy on disease perception and pain perception in patients with rheumatoid arthritis. Sci J Kurdistan Med Sci. 2014; 20(3): 45-47. doi: 10.22102/20.3.45

Karbalaie M, Yazdanbakhsh K, Karimi P. Predicting Psychological Well-Being Based on Emotion Regulation, Cognitive Flexibility and Mindfulness in Cancer Patients. Quarterly J Health Psychol. 2021; 10(1): 141-160. doi: 10.30473/hpj.2021.50258.4653.

Simard S, Savard J. Fear of Cancer Recurrence Inventory: development and initial validation of a multidimensional measure of fear of cancer recurrence. Support Care Cancer. 2009; 17(3): 241-251. doi: 10.1007/s00520-008-0444-y.

Bateni FS, Rahmatian M, Kaviani A, Simard S, Soleimani M. Nejatisafa A A. The Persian Version of the Fear of Cancer Recurrence Inventory (FCRI): Translation and Evaluation of Its Psychometric Properties. Arch Breast Cancer. 2019; 6(4): 174-180. doi: 10.32768/abc.201964174-180.

Garnefski N, Kraaij V. Cognitive emotion regulation questionnaire – development of a short 18-item version (CERQ-short). Pers individ differ. 2006; 41(6): 1045-1053. doi: 10.1016/j.paid.2006.04.010

Mohsenabadi H, Fathi-Ashtiani A. Evaluation of psychometric properties of the Persian version of the short form of Cognitive Emotion Regulation Questionnaire (CERQ-18). Payesh. 2021; 20 (2):167-178. doi:10.52547/payesh.20.2.167

Broadbent E, Petriea K J, Maina J, Weinman J. The Brief Illness Perception Questionnaire. J Psychosom Res. 2006; 60: 631– 637. doi: 10.1016/j.jpsychores.2005.10.020.

Karimi-Ghasemabad S, Akhbari B, Saeedi A, Talebian Moghaddam S,. Nakhostin Ansari N. The Persian Brief Illness Perception Questionnaire: Validation in Patients with Chronic Nonspecific Low Back Pain. Sci World J. 2021; 1-6. doi:10.1155/2021/3348011.

Ryff C D, Keyes C L. (1995).The structure of psychological well-being revisited. J Pers Soc Psychol. 69(4), 719-727. doi: 0.1037/0022-3514.69.4.719

Khanjani M, Shahidi Sh, Fath-Abadi J, Factor structure and psychometric properties of the Ryff’s scale of Psychological well-being, short form (18-item) among male and female students. J Thought Behavior Clin Psychol. 2014; 8 (32): 27-36. https://jtbcp.riau.ac.ir/article_67_en.htm.

Mallinckrodt B, Abraham WT, Wei M, Russell DW. Advances in Testing the Statistical Significance of Mediation Effects. J Counsel Psychol. 2006; 53 (3): 372–378. doi:10.1037/0022-0167.53.3.372.

Shaw J, Kamphuis H, Sharpe L, Lebel S, Ben Smith A, Williams N H, et al. Setting an International Research Agenda for Fear of Cancer Recurrence: An Online Delphi Consensus Study. Fronitiers Psychol. 2021; 12: 1-10. doi: 10.3389/fpsyg.2021.596682.

Tomei Ch, Lebel S, Maheu Ch, Lefebvre M, Harris Ch. Examining the preliminary efficacy of an intervention for fear of cancer recurrence in female cancer survivors: a randomized controlled clinical trial pilot study. Support Care Cancer. 2018; 26(8), 2751-2762. doi:10.1007/s00520-018-4097-1

Lebel S, Maheu Ch, Tomei Ch, Bernstein M, Lori J d, Courbasson Ch, et al. Mechanisms of change of a cognitive-existential group intervention for fear of cancer recurrence: mediation analyses of the FORT trial. J Psycho-Oncology Res Pract. 2022; 4(3), doi: 10.1097/OR9.0000000000000077.

Tauber N M, O’Toole M S, Dinkel A, Galica J, Gerry Humphris G, Lebel S, et al. Effect of Psychological Intervention on Fear of Cancer Recurrence: A Systematic Review and Meta-Analysis. J Clin Oncol. 2019; 37(31): 2899–2915. doi: 10.1200/JCO.19.00572.

Conley C C, Bishop B T, Andersen L B. Emotions and Emotion Regulation in Breast Cancer Survivorship. Healthcare. 2016; 4(3), 56. doi.org/10.3390/healthcare4030056.

Shim E J, Lee J W, Min Y H. Does depression decrease the moderating effect of self-efficacy in the relationship between illness perception and fear of progression in breast cancer? Psycho-oncology. 2018; 27(2):539-547. doi: 10.1002/pon.4532. 2017

Zhang N, Fielding R, Soong I, Chan K K, Lee C, Alice Ng, et al. Illness perceptions as predictors of psychological distress among head and neck cancer survivors: a longitudinal study. Head Neck. 2018; 40(11):2362-2371. doi: 10.1002/hed.25343.

Tekir O. The relationship between fear of COVID-19, psychological well-being and life satisfaction in nursing students: A cross-sectional study. Plos one. 2022; 1-15. doi:10.1371/journal.pone.0264970.

Lathabhavan R. Fear of COVID 19, psychological distress, well being and life satisfaction: A comparative study on first and second waves of COVID 19 among college students in India. Curr Psychol. 2022; 1-8. doi:10.3389/fpsyg.2020.565153.

Sayeed Khan M N, Naser A, Zulqarnain A, Naz A. Illness Perception, Cognitive Emotional Regulation and Quality Of Life in Chronic Pain Patients. Res Gate. 2016, researchgate.net/publication/311627572.

Salajegheh S, Emamipour S, Nematolah Zadeh Mahani K. Explaining structural modeling of the relationship between self-coherence and mental well-being based on the mediating role of cognitive emotion regulation strategies in women with breast cancer. J Thought Behavior Clin Psychol. 2017; 11(45): 67-76. https://jtbcp.riau.ac.ir/article_1210_en.html.

Erisian Z, Torkan H, Mokarian F. Simple and Multiple Relationships of Emotional Regulation, Pain Self-efficacy and Perception of Disease with Psychological Well-being in Breast Cancer Women. J clin Psychol. 2019; 11(41):49-59. doi:10.22075/JCP.2019.16415.1567.

Balzarotti S, Biassoni F, Villani D, Prunas A, Velotti P. Individual Differences in Cognitive Emotion Regulation: Implications for Subjective and Psychological Well-Being. J Happiness stud. 2016; 17, 125–143. doi: 10.1007/s10902-014-9587-3.


Sedigheh Hosseini
hoseini.af@gmail.com (Primary Contact)
Mahdiee Salehi
Mohsen Jadidi
Mahdi Aghili
Hosseini S, Salehi M, Jadidi M, Aghili M. A Structural Model Explaining the Effect of Cognitive Emotion Regulation on the Fear of Cancer Recurrence in Breast Cancer Survivors: the Mediating Roles of Illness Perception and Psychological Well-being: Emotion regulation of FCR. Arch Breast Cancer [Internet]. 2023 Apr. 6 [cited 2024 Apr. 14];10(2):138-47. Available from: https://www.archbreastcancer.com/index.php/abc/article/view/665

Article Details

Most read articles by the same author(s)