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The mediating effect of intrusive rumination on the relationship between illness uncertainty and fear of cancer recurrence in breast cancer survivors

BMC Women's Health volume 25, Article number: 41 (2025) Cite this article

Abstract

Background

Recently, increased awareness of early diagnosis and treatment options has led to an increase in the number of breast cancer survivors. Psychosocial interventions to increase the quality of life in this group are gaining importance. One of the most common psychological problems in breast cancer survivors is fear of cancer recurrence (FCR). It is essential to elucidate the mechanisms of FCR. Aims: This study aimed to examine the mediating effect of intrusive rumination on the relationship between illness uncertainty and FCR in breast cancer survivors.

Methods

The study was designed to be cross-sectional, and 204 breast cancer survivors were included. Participants were given the Mishel Uncertainty in Illness Scale-Community form (MUIS-C), the severity subscale of the Fear of Cancer Recurrence Inventory, and the Event-Related Rumination Inventory-intrusive rumination subscale. Correlation analyses were conducted, and the structural equation method evaluated the mediation effect.

Results

Most participants (74%) reported some degree of FCR. A significant positive relationship was found between illness uncertainty and FCR (r = 0.325; p ≤ 0.001). The path analysis showed that intrusive rumination partially mediates this relationship.

Conclusions

This study’s results shed light on the relationship between illness uncertainty, rumination, and FCR. Planning psychoeducation programs during follow-up to reduce illness uncertainty may positively affect FCR. In addition, metacognitive therapies that can functionalize the ruminative thinking style can also effectively intervene in FCR.

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Introduction

Breast cancer is the most frequently diagnosed type of cancer and the primary cause of cancer-related mortality among women globally. It is responsible for around 25% of new cancer cases and 16% of cancer-related deaths in 2020 [1]. Early diagnosis and increased awareness through routine mammography screenings, as well as advances in treatment options, have increased the number of breast cancer survivors [2]. The increasing life expectancy of breast cancer survivors makes it essential to monitor the mental well-being of this group. Anxiety and depression are more common in breast cancer survivors than in the general population [3, 4]. The “fear of cancer recurrence (FCR)” is defined as fear/anxiety about the recurrence or spread of the disease. FCR is also a common mental distress and affects 22–87% of individuals diagnosed with cancer [5]. Considering the quality of life-reducing effects of a cancer diagnosis and treatment, FCR can be considered a reasonable response. However, it has been shown that high levels of FCR are associated with anxiety, depression, and low quality of life in individuals [6, 7].

Various models have been developed to understand the formation mechanisms of FCR [8,9,10,11]. Current theories and formulations proposed and applied to FCR are all drawn from the cognitive behavioral paradigm. Leventhal’s Common-Sense Model of Disease (CSM) states that internal and external stimuli activate FCR-related cognitive responses. It is a multidimensional structure in which the person’s perceived risk of recurrence increases based on the disease representation [12]. For the formation of FCR when external and internal stimuli activate specific cognitive and emotional themes related to the presentation of the disease in the individual, uncertainty mediates the relationship between triggers and perceived risk perception so that high levels of uncertainty result in high FCR [13]. Uncertainty is common in health, just like in other aspects of life. However, not all cancer patients develop FCR. This indicates that there may be differences in potential cognitive processing styles between FCR and illness uncertainty (IU), which vary depending on the individual. One of these differences may be rumination. According to Response Styles Theory, rumination is an inconvenient cognitive pattern characterized by an excessive focus on repetitive unpleasant thoughts related to the symptoms, causes, and outcomes of emotional discomfort [14]. FCR includes the impression of a future threat and concern. On the other hand, rumination is related to an increased ability to remember bad events from the past, a more negative perspective on the present, and a tendency to view the future with heightened negativity and despair [15]. Previous distressing experiences can modify FCR, which encompasses worries about future risks. Reflecting on distressing life events, such as previous diagnoses and treatments, can impact the level of anxiety that one experiences about the possibility of cancer returning in the future.

On the other hand, patients with breast cancer, when they evaluate uncertainty as a traumatic event, may use rumination as a coping mechanism. Although rumination provides distance from the emotional components of the traumatic memory in the short term [16], it leads to catastrophizing scenarios in the long term. Thus, it may have resulted in higher FCR.

The relationship between FCR, IU, and rumination has not been previously examined in the literature. In light of all this information, the current study aimed to investigate the effect of rumination on the relationship between IU and FCR. Understanding the cognitive processes, from uncertainty experienced by patients to fear of cancer recurrence, will expand intervention options for FCR. Therefore, we first hypothesized that there would be a positive correlation between FCR, IU, and rumination. In our second hypothesis, we assumed that individuals with higher IU ​​experience more FCR, and this relationship may mediated by rumination.

Materials and methods

Study design and participants

This study was designed as a cross-sectional study following STROBE guidelines. Participants who met the inclusion criteria among breast cancer survivors who applied to the Medical Oncology outpatient clinic between February 2024 and June 2024 were included in the study. Inclusion criteria were being diagnosed with early-stage or locally advanced (non-metastatic) breast cancer who have completed the treatment process and are being followed up in remission, being over 18 years of age, knowing how to read and write Turkish, and not having a severe mental or neurological disorder. Patients who agreed to participate in the study were asked to fill out an informed volunteer form, and self-report questionnaires required for the study were distributed. Since a sample size between 30 and 460 was appropriate depending on the structural equation model (SEM) [17] requirements, 240 early-stage breast cancer patients were reached: 230 agreed to participate in the study. Because 26 out of 230 participants did not complete the survey questions, 204 were included in the final data analysis.

Procedure

In this study, participants were given three self-report scales following the sociodemographic data form: Mishel Uncertainty in Illness Scale-Community form (MUIS-C), severity subscale of the Fear of Cancer Recurrence Inventory, and Event-Related Rumination Inventory (ERRI). Participants perused the informed consent form, confirming the study’s goal and significance. A team of evaluators consisting of two medical oncologists collected the filled-out questionnaires on-site.

Variables

The sociodemographic data form consisted of questions filled out by the participants, including education level, marital status, living environment, employment status, age, and whether they had been diagnosed with cancer before. Medical chart reviews provided the tumor stage, the type of treatment, and the date of diagnosis.

The Fear of Cancer Recurrence Inventory (FCRI) is a self-report-based 5-point Likert scale consisting of 42 questions that evaluate seven components of FCR (triggers, severity, psychological distress, coping strategies, functional impairment, reassurance, and insight) as subscales [5]. This scale has shown good psychometric properties in Turkish cancer patients [18]. This study used the severity subscale because the strong correlations between the severity subscale and the total FCRI (also named Fear of Cancer Recurrence Inventory-Short Form) showed that the severity subscale was suitable as a brief FCR assessment for screening [19]. Fear of Cancer Recurrence Inventory-Short Form is a nine-item scale with a score range between 0 and 36. In this scale, “12” was taken as the cut-off value [20]. Using a cut-off value is helpful in terms of screening those with clinically significant FCR.

Mishel Uncertainty in Illness Scale-Community form (MUIS-C) consists of 20 self-report questions in a 5-point Likert format [21]. The Turkish version of this scale is evaluated according to the total score and the score for each of the three dimensions: perception of the current situation, perception of understanding, and ambiguity [22]. The perception of the current situation subscale scores range from 11 to 55, the perception of understanding subscale scores range from 4 to 20, and the ambiguity subscale scores range from 5 to 25. The total score that can be obtained from the scale varies between 20 and 100.

The Event-Related Rumination Inventory (ERRI) was developed by Cann et al. to evaluate the presence of repetitive thoughts about a stressful event. It consists of two subscales, “intrusive/involuntary rumination” and “deliberate rumination”, and 20 self-report questions in the form of a 4-point Likert [23]. The total score varies between 0 and 30. The validity and reliability of the scale in Turkish have been demonstrated [24], and only the intrusive/involuntary rumination subscale will be used in this study.

Statistical analysis

Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) (Version 22.0) and Analysis of Moment Structures (AMOS) statistical software programs (Version 28.0). All scales (MUIS-C, FCRI-severity subscale, and ERRI-intrusive rumination subscale) showed acceptable internal consistency with Cronbach’s alpha in our sample. 0.818, 0.838, and 0.937, respectively. Descriptive analyses were used to summarize the demographic characteristics of the study sample, i.e., mean, standard deviation (SD), frequencies, and percentages. Relationships between study variables were measured using Pearson correlation coefficients for continuous scales. Path analysis was used to analyze the direct and indirect mediation relationship of rumination between IU and FCR. This study applied a structural equation modeling (SEM) approach using maximum likelihood estimation for path analysis. The goodness of fit of the SEM model was evaluated using the chi-square statistic, comparative fit index (CFI), Tucker-Lewis index (TLI), and root mean squared approximation (RMSEA). Statistical significance was determined as a p-value < 0.05. The fit index examines how well the collected data fit the hypothesized model [25]. The generally accepted critical value varies between 0 and 1, with a TLI and CFI value of 0.90 indicating good fit and 0.80 < TLI/CFI < 0.90 indicating marginal fit. Additionally, root mean square error of approximation (RMSEA) was used and evaluated using the criterion that a low value (between 0 and 0.06) indicates a good fit model [26].

Results

Characteristics of participants

Of the 230 early-stage breast cancer patients who agreed to participate in the study, 204 answered all the survey questions (response rate: 88.6%). The ages of the participants ranged between 28 and 80, and the mean age was 51.96 ± 9.49. The time since diagnosis ranged between 1 and 26 years, and the mean time was 5.9 ± 4.9 years. 77.9% of the participants were married. 31.9% of the subjects had a familial predisposition to breast cancer. 53.9% of the participants were diagnosed with stage II breast cancer, and all of the participants underwent breast surgery. The demographic characteristics of the participants are shown in Table 1.

Table 1 Descriptive analysis of participants
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Participants’ FCR, MUIS-C, ERRI-İntrusive rumination

The FCRI-Severity score of the participants was found to be 16.58 ± 7.04. According to the cut-off point 12, 74% of participants reported some degree of FCR. The participants’ mean scores on the ERRI-intrusive rumination subscale were 14.53 ± 7.85, and MUIS-C scores were 46.29 ± 13.86. The scale and subscale scores of the participants are shown in Table 1.

Differences in IU, FCR, and ERRI-intrusive rumination according to demographic and clinical characteristics

Differences in FCR, IU, and intrusive rumination according to demographic and disease-related characteristics are shown in Table 2. There was no significant difference between FCR, MUIS-C, and intrusive rumination among breast cancer stages. Intrusive rumination was found to be higher in those with previous cancer recurrence (t = 2.002; p = 0.029), and MUIS-C was found to be lower in those with a family history of cancer (t=-2.000; p = 0.047). MUIS-C was also significantly lower in those with a university level of education or higher (F = 5.698; p = 0.004). No significant difference was observed in FCR, MUIS-C, and Intrusive rumination scores between those younger than 50 and those older than 50, as well as between those married and others.

Table 2 Differences in IU, FCR, and ERRI-intrusive rumination according to demographic and clinical characteristics
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Relationships between FCR, rumination, and illness uncertainty

Pearson correlation analysis (Table 3) showed that FCR (i.e., FCRI-Severity total scores) was significantly and positively correlated with intrusive rumination (r = 0.641; p < 0.001). FCR showed a significant and positive correlation with IU (i.e., MUIS-C total and dimension scores) (r = 0.325; p < 0.001). Additionally, intrusive rumination had a significant and positive relationship with IU (r = 0.273; p < 0.001).

Table 3 Relationships between FCR, rumination, and illness uncertainty
Full size table

Intrusive rumination mediates the relationship between IU and FCR

Analysis of Moment Structures (AMOS) statistical software program (Version 28.0) was used to examine the mediating effect of intrusive rumination between IU and FCR. Structural equation modeling (SEM) was used to analyze the mediation effect. All path coefficients were statistically significant. Results showed a marginal fit of the model to the data [χ2 (df = 681) = 1015.351 χ2/df = 1.491; RMSEA = 0.049; TLI = 0.909 and CFI = 0.917]. This study estimated the mean of the 95% confidence intervals (CI) of indirect effects from 2000 bootstrap samples. If the upper and lower limits of the CI do not contain zero, the existence of an indirect effect can be decided with 95% confidence. Bootstrap results showed that rumination partially mediated the link between IU and FCR [95% CI (0.089, 0.304)]; indirect effect = 0.190, SE = 0.054, p < 0.001; total effect = 0.468, SE = 0.075, p < 0.001; direct effect = 0.278, SE = 0.064, p < 0.001. Figure 1 shows the mediating effect of intrusive rumination on the relationship between IU and FCR.

Fig. 1
figure 1

Mediating effect of intrusive rumination on the relationship between IU and FCR. The final model for the whole sample (n = 204), with standardized beta weights and significant level, **p < 0.001

IU: illness uncertainty, FCR: fear of cancer recurrence

Full size image

Discussion

This study examined the effect of intrusive rumination on the relationship between FCR and IU in women with early-stage breast cancer. According to the results, there was a significant positive relationship between IU and intrusive rumination and FCR. The relationship between IU and FCR was mediated by intrusive rumination. This study is the first to examine whether intrusive rumination acts as a mediator between fear of cancer recurrence (FCR) and illness uncertainty (IU).

Only 10–15% of patients with breast cancer are in the metastatic stage at the time of diagnosis [27]. Groundbreaking developments in the treatment of early-stage breast cancer and the fact that most patients are at an early stage at the time of diagnosis have increased the life expectancy, and the increased survival time and long follow-up period have made it necessary to examine the mental health and quality of life of patients as well as their physical health [10]. In this context, the most common psychological problem in cancer patients is FCR [28], and in this study, the FCR Severity score in the patients was found to be 16.58 ± 7.04. When the FCR-Severity cut-off value was taken as 12, FCR was detected in 74% of the patients. A meta-analysis including 9311 participants showed that more than half (59%) of cancer patients and cancer survivors had FCR [29].

When the relationships between the sociodemographic and clinical characteristics of the participants and FCR, IU, and Intrusive Rumination were examined, no connection was found between FCR and age, time since diagnosis, or disease stage in this study. Previous studies have shown that FCR is significantly higher in young cancer survivors [30, 31]. Our study group consisted of early-stage breast cancer patients. Increased life expectancy and advanced treatment options in recent years may have increased the belief in the controllability of cancer in our sample [32, 33]. Therefore, the negative relationship between age groups and FCR may not have been shown in our sample.

IU significantly decreased in our study as the education level increased. Uncertainty occurs when patients’ expectations are inconsistent with the disease experience [34]. The patient’s cognitive capacity influences uncertainty by interpreting disease-related stimuli. A more robust cognitive capacity makes it easier for the patient to understand stimuli, which reduces his uncertainty [35]. In our study, cognitive capacity was not measured directly but indirectly by reference to education level. Liao et al. showed that low education levels predicted uncertainty [36]. Similar results were confirmed in a recent study by Chen et al. [37]. Additionally, in this study, MUIS-C scores were significantly lower in those with a family history of breast cancer compared to those without a family history. Cancer survivors’ perceptions and interpretations of stressful disease events are effective factors in the emergence of uncertainty about the disease [35]. Experiencing this experience in the individual’s environment may reduce patients’ feelings of loneliness and helplessness regarding the disease. This may make sense of the impact of family history on uncertainty.

Finally, in our study, patients with a previous cancer recurrence/history had significantly higher intrusive rumination scores. According to the cognitive model of Posttraumatic Stress Disorder, individuals who think of a traumatic incident as potentially harmful typically attempt to deal with it by utilizing the maladaptive cognitive processing style of rumination [38]. This may indicate that invasive rumination scores in people with a history of recurrence/previous cancer are related to impaired cognitive processing due to the traumatic event experienced.

Consistent with the study’s hypotheses, a significant positive relationship was found between FCR and IU. Uncertainty, the inability to determine the meaning of illness-related experiences, occurs when the person cannot create a cognitive schema about the illness. It has been found that uncertainty reduces a person’s sense of control over events [34] and increases the sense of danger [39]. Uncertainty may be perceived as a death threat in cancer survivors and may ultimately cause them to experience FCR. This is consistent with Mishel’s uncertainty in illness theory. However, when evaluated with a probabilistic paradigm, uncertainty is understood as a natural condition of life and is likely to lead to greater perceptions of opportunity and meaning [10]. In this context, uncertainty may have an essential role in increasing not only the fear of cancer recurrence but also the hope that cancer will not recur. The dual process model developed by Han et al. showed that uncertainty is an essential source of both fear and hope and which one prevails is related to the person’s positive and negative coping skills [40].

At this point, it becomes crucial to investigate the ways to relate the uncertainty about the disease to the fear of cancer recurrence. We added intrusive rumination to our study as a factor likely to mediate this relationship. First of all, we observed a significant positive relationship between intrusive rumination and fear of cancer recurrence. High FCR leads to excessive triggering regarding the experience of the traumatic event, and individuals may enter a vicious circle between intrusive ruminative thoughts about previous cancer experiences and worry about the possibility of the experience [41]. On the other hand, rumination is a form of cognitive avoidance. It is known that individuals who have experienced trauma continue rumination by focusing on less concrete verbal channels to escape intrusive memories [42]. Although ruminative thoughts provide a temporary distraction from the most emotional moments of the trauma, they help to avoid it in the beginning; there is a high possibility of increasing anxiety later on because their content is negative [16].

The findings of this study validate our second hypothesis, which suggests that intrusive rumination plays a partial role in mediating the impact of IU on FCR. Uncertainty theory explains how patients cognitively process disease-related stimuli and construct the meaning of these events. If uncertainty is considered a danger, a harmful outcome expectation arises, activating coping strategies to reduce uncertainty [43]. One of these coping mechanisms may also be ruminative thinking, which is led by evaluating danger and uncertainty [44]. Additionally, a traumatic event such as being diagnosed with cancer may activate rumination, a cognitive avoidance strategy, in people to avoid involuntary memories of the trauma [16]. Rumination of distressing life experiences, such as previous medical diagnosis and treatment, might impact one’s anxiety around the possibility of cancer recurring in the future, leading to FCR [15].

Limitations

This study has a few limitations. First, causal relationships could not be demonstrated since the study design was cross-sectional and the convenience sampling method was used. Second, our sample was drawn from a single-center hospital in Turkey and may not sufficiently represent the population. Therefore, more extensive studies are needed to repeat our results in other hospitals and confirm our results. Finally, the assessment of rumination, fear of cancer recurrence, and illness uncertainty was based on patients’ self-reports, which may affect data accuracy.

Clinical implications

The findings of the present investigation offer significant insights into the implementation of medical procedures. The presence of uncertainty in cancer disease is a significant concern for patients, and the capacity to manage this uncertainty is a crucial determinant in the development of FCR. Physicians and nurses can inform patients that FCR is a normal reaction and that uncertainty exists in every aspect of life. This information can help patients normalize their fears and increase their awareness of coping with uncertainty. A recent study has shown that psychoeducation on FCR in patients with malignant melanoma reduces long-term development of FCR [45]. Additionally, the study found that rumination mediated the relationship between uncertainty and FCR. Offering psychotherapies (metacognitive therapies, awareness-focused therapies) that reduce ruminative thinking style to patients at an early stage may contribute to reducing FCR by reducing ruminative thinking style. A review has indicated that cognitive behavioral therapy can lessen the severity of FCR in cancer survivors [46].

Conclusion

The results of this study shed light on the relationship between illness uncertainty, rumination, and FCR. FCR remains a significant psychological response in cancer survivors. Planning the necessary social support and psychoeducation programs during follow-up processes to reduce illness uncertainty may positively impact FCR. In addition, metacognitive therapies that can make ruminative thinking style functional may also effectively intervene in FCR.

Data availability

The datasets generated and/or analyzed during the current study are not publicly available due to restrictions from the ethics committee but are available from the corresponding author upon reasonable request.

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Acknowledgements

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Funding

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Authors and Affiliations

  1. Department of Medical Oncology, Dr. Abdurrahman Yurtaslan Ankara Oncology Research and Training Hospital, Ankara, Turkey

    Alper Türkel, Ahmet Kadıoğlu & Mutlu Doğan

  2. Department of Psychiatry, Ankara Penitentiary Campus State Hospital, Ankara, Turkey

    Nur Nihal Türkel

  3. Department of Psychiatry, Gazi University Faculty of Medicine, Ankara, Turkey

    İrem Ekmekçi Ertek

Authors
  1. Alper Türkel
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  2. Nur Nihal Türkel
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  3. Ahmet Kadıoğlu
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  4. Mutlu Doğan
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  5. İrem Ekmekçi Ertek
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Contributions

NNT designed the study; MD and IEE were supervisors. AT and AK processed the data; NNT and AT drafted the manuscript; MD and IEE analyzed and interpreted the results; all authors reviewed the paper for intellectual content. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Alper Türkel.

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Ethical approval

The study received ethical approval from the Gazi University Faculty of Medicine Ethics Committee following the Declaration of Helsinki (no:2024 − 270, date:13.02.2024). By the Declaration of Helsinki, participants were provided with information regarding the objectives and methodologies of the study prior to its commencement. Participants could withdraw from the study and were not obligated to respond to any inquiries. Each participant received signed informed permission, demonstrating their complete comprehension of the study protocols.

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Informed consent to participate was obtained from all of the participants.

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The authors declare no competing interests.

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Türkel, A., Türkel, N.N., Kadıoğlu, A. et al. The mediating effect of intrusive rumination on the relationship between illness uncertainty and fear of cancer recurrence in breast cancer survivors. BMC Women's Health 25, 41 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03580-y

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12905-025-03580-y

Keywords

BMC Women's Health

ISSN: 1472-6874

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