Associations of Fear of Cancer Recurrence between Health Behaviors and Health Service Use: A Systematic Review

Background and Purpose: Recent national reports underscore the importance of delivering high quality cancer care, reducing potentially avoidable health service use, and increasing engagement in improved health behaviors among cancer survivors.  Fear of cancer recurrence (FCR) is common during cancer survivorship and may influence health behaviors and health service use; however, very little research has focused on these relationships. This systematic review was conducted to improve our understanding of the relationship between FCR and engagement in health behaviors and/or health service use.

Methods: A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was performed to identify any publications that examined FCR or related constructs, and health behaviors and/or health service use in the following databases: PubMed, CINAHL and PsychINFO from January 1990 to December 2018.  Eligible studies needed to be published in a peer-reviewed journal; written in English; include an adult population, 18 years or older; identify cancer survivors with FCR or similar construct; and quantify their health service use or health behavior. The references in the identified papers were reviewed to include additional articles.  Quality was assessed using QualSyst, a standard quality assessment for evaluating primary research papers.

Results: Fifty articles met the inclusion criteria but were too heterogeneous to combine in statistical meta-analysis. While multiple cancer diagnoses were included, most studies (36%) focused on breast cancer.  Few studies reported racial/ethnic characteristics of their participants (28%); of those, most participants were white, non-Hispanic. The measurement of FCR or similar constructs varied widely and was inconsistent across studies. The most common measure was the Hospital Anxiety and Depression Scale (HADS) and among FCR specific measures, there was no consistency in the selected tool. The most frequently examined health behaviors were smoking status and physical activity, with far fewer studies examining health service use. Overall, most studies demonstrated a positive relationship between moderate to high FCR (or related construct) and poor health behaviors or increased health service use.  Overall, studies had fair methodological quality.  

Conclusions and Implications: Opportunities exist to extend future research in order to better understand the relationships between FCR, health behaviors and health service use.  We recommend that FCR be included in research examining health behaviors and health service use, particularly in longitudinal study designs and with racially and ethnically diverse populations. Given the measurement heterogeneity of FCR and related constructs, future research would also benefit from consistent operationalization and measurement. As evidence suggests that FCR is positively related to poor health behaviors, research and clinical interventions may choose to focus on early post-treatment survivorship when opportunities for support and intervention around FCR and other psychosocial concerns are more likely. Additionally, there may be opportunities to focus on health behaviors and/or health service use that are most responsive to intervention (e.g. guidance around health service use through cancer survivorship plans).