Factors associated with high fear of cancer recurrence in young- and middle-aged patients with lung cancer:A cross-sectional study applying the social-ecological model

Factors associated with high fear of cancer recurrence in young- and middle-aged patients with lung cancer:A cross-sectional study applying the social-ecological model | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Factors associated with high fear of cancer recurrence in young- and middle-aged patients with lung cancer:A cross-sectional study applying the social-ecological model Qin Wang, Guanghui XIA, Feng Liu, Xiaoxin Yang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5322961/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives To identify the factors associated with FCR in young- and middle-aged patients with lung cancer (LC) by applying the social-ecological mode through a cross-sectional study design. Methods A total of 16 5 patients aged 18–64 years at diagnosis, were recruited to completed the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), Brief Illness Perception Questionnaire, Perceived Social Support Scale, Brief Fatigue Inventory, and Hospital Anxiety and Depression scale. Self-reported questionnaires and electronic medical records were used for collecting sociodemographic and clinical variables. Results The mean FoP-Q-SF score was 30.12 ± 10.12; 59 patients (35.8%) had high FCR as indicated by a score of ≥ 34. Multiple linear regression analyses showed that factors in the intrapersonal level including female ( p < 0.001), illness perception ( p < 0.01), and fatigue (p < 0.01), and factors in the interpersonal level including only child ( p < 0.01) and social support (p < 0.01), and the factor in the social-economic level including working status( p < 0.000), were independent predictors of high FCR. Conclusions Multiple factors influence FCR in young- and middle-aged patients with LC.We suggest screening and early detection of FCR based on the above predictors. Meanwhile,multidimensional perspectives, including intrapersonal, interpersonal, and social-economic levels, should be used to develop comprehensive FCR management strategies. Young- and Middle-Aged Lung Cancer Fear of Cancer Recurrence Social Ecological Model Psycho-Oncology Risk Factors Figures Figure 1 Introduction Lung cancer (LC) is the leading cause of cancer-related mortality in China. Although more common in males and older patients, a trend towards the younger population is observed, particularly among young women [ 1 – 2 ]. The incidence and mortality of LC in China increases significantly after the age of 45 years, and patients under 40 are commonly affected [ 2 ]. Further, LC mortality rates among young men and women are the second and third highest, respectively, among other malignant tumor mortality rates [ 1 , 3 ]. The age for early LC screening according to the latest Chinese guidelines for diagnosing and treating LC has been lowered from 50 to 45 years [ 4 ]. Young patients with LC achieve better treatment outcomes after receiving surgery, chemotherapy, or novel targeted and immunotherapy, and have relatively longer relapse-free survival, indicating prolonged survival [ 5 – 7 ]. Despite advances in the treatment and prognosis of LC, many survivors are at risk of cancer recurrence. This uncertainty can cause patients to experience fear of cancer recurrence (FCR), including anxiety and worry of progression [ 8 ]. The incidence of FCR in patients is nearly 72% due to the high mortality rates of LC [ 9 ]. Low FCR can be an incentive for patients to adopt healthy behaviors and adhere to treatment [ 8 – 10 ]. However, high FCR leads to reduced quality of life, functional decline, psychological distress, and frequent clinic visits [ 9 , 10 – 11 ]. Young age is the most consistent predictor of an increase in FCR in patients with cancer [ 12 – 13 ]. Young patients with LC are a vulnerable population who are the primary support to their families and shoulder more financial and family responsibilities [ 14 ]. At the same time, the physical dysfunction and social damage due to the disease and treatment may affect their functioning and even lead to discrimination. As a result, young LC survivors are more likely to experience depression and anxiety [ 15 ], further exacerbating FCR. An important first step in the development of appropriate strategies for the management of FCR among patients is an understanding of the factors associated with it. Previous studies on FCR among young individuals were focused on breast cancer [ 11 – 12 ]. However, the severity of FCR varies according to cancer type, treatment, clinical course, and prognosis [ 16 ]. Meta-analyses have shown that the incidence of FCR is higher in patients with LC than in patients with breast cancer[ 17 ]. Although some studies have focused on patients with LC, these have included a mixed age samples [ 9 , 16 ]. In addition, FCR is a multidimensional phenomenon that may be influenced by several factors [ 12 , 16 ]. However, much of the existing research is focused on individuals (e.g., sociodemographic and clinical cancer variables) [ 9 – 10 , 16 ]. Socio-ecological psychology highlights that the natural and social environment can influence the behavior of individuals. If human psychology and behavior are to be understood, they must be studied in the context of socio-ecological systems [ 19 ]. Social factors also affect FCR. For example, there is a significant difference in the mean level of FCR between racial and ethnic groups [ 20 ]. Chinese women have lower levels of FCR than women in other Asian countries [ 21 ]. Moreover, social support reduces FCR[ 22 ]. The socio-ecological model (SEM) views the social environment in which people live as a complete ecosystem and emphasizes that human behavior is influenced by various factors in the system[ 23 ]. The SEM provides new explanations for the development of human behaviors.Exploring FCR from a socio-ecological perspective allows for a more comprehensive and systematic analysis of the factors influencing FCR. Currently, studies are conducted to apply the SEM theory to understand the factors of parental psychological distress in the neonatal intensive care unit (NICU) [ 24 ]. The aim of this study was to assess the prevalence of FCR in young- and middle-aged patients with LC by applying the SEM and to explore the factors influencing FCR. Methods 2.1 Study design A total of 165 young- and middle-aged patients with LC from the largest chest hospital in Nanjing, China, were selected by convenience sampling for this cross-sectional study. All participants were invited to fill in the questionnaires from the 11 October 2022 to the 27 May 2023. 2.2 Ethical considerations The Ethics Committee affiliated with the Nanjing Medical University approved the study (No. 2022-KY066-01), and all participants provided consent forms before data collection. 2.3 Sample and setting The National Comprehensive Cancer Network guidelines on geriatric oncology define patients ≥ 65 years of age as elderly [ 25 ]. In China, patients with LC between 18 and 45 years are defined as young [ 26 ]. Based on these criteria, this study defined young- and middle-aged patients with LC as those in the 18–45 years group and 46–64 years group, respectively. Inclusion criteria were (1) age of 18–64 years; (2) diagnosis of LC and knowledge of their condition; and (3) ability to complete questionnaires independently or with assistance. Exclusion criteria were (1) presence of malignant fluid; (2) history of other cancer; (3) severe hearing and visual impairment; (4) severe mental and psychological disorders; and (5) presence of severe physical, heart, liver, kidney disease, or disability. The sample size for this study was determined using Kendall's principle, which recommends a sample size of 5–10 times the number of variables [ 27 ]. This study included 23 variables with a missing data rate of 20%. Therefore, a minimum sample size of 144–287 cases was required, calculated using the formula (23[ 5 – 10 ]/[1–20%]). The number of patients in the study was 165, more than the minimum sample size requirement. 2.4 FCR-related independent variables The social-ecological mode(SEM) [ 23 ] involves humans and their living environments and states that individual behavior is affected by many internal and environmental factors, forming intrapersonal,interpersonal,organization,community,and policy levels (Table 1 ) .A comprehensive review of the possible predictors of FCR was conducted in young- and middle-aged patients with LC based on a literature review [9–10 12 , 14 , 16 , 18 , 28 – 30 ] and considering the clinical component of LC. TABLE 1: Level of an ecological perspective Level Definition Intrapersonal Individuals in a sociological environment that includes individual demographics, health conditions, and others Interpersonal Small-scale environment directly related individuals' family, work group, friendship, and medical staff networks that provide social identity, support, and role definition Organization Rules, regulations, policies, and informal structures that may constrain or promote recommended behaviors Community Social networks and norms, or standards, which exist formally or informally among individuals, groups, and organizations Policy Outer environmental factors, such as culture, laws, and policies, which affect individuals Two researchers descriptively summarized (Y.L., G.H.X) the factors associated with FCR in LC patients and classified these factors into different levels of SEM.The intrapersonal level was based on biological and individual characteristics.At the interpersonal level, factors were classified based on various networks, (e.g., family, friends, work groups, and medical staff).At the social-economic level the factors were classified into living and working conditions.At the community/public policy level, the factors were classified into politics and culture. Consensus on disagreements was attained through in-depth discussions with the third author (X.X.Y)(Fig. 1). Figure 1 Construct of the FCR factors based on the SET 2.5 Measures 2.5.1 Fear of Progression Questionnaire-Short Form (FoP-Q-SF) Mehnert et al developed the Fear of Progression Questionnaire Short Form (FoP-Q-SF) [ 31 ]. The instrument consists of 12 items in two dimensions, namely physical health and social family. The items are scored on a scale of 1 to 5, from "never" to "always". The total scores range from 12 to 60, with higher scores indicating higher levels of FCR. A total score of ≥ 34 is the clinically defined threshold [ 22 ]. The Cronbach's alpha coefficient for FoP-Q-SF was 0.866. 2.5.2 Brief Illness Perception Questionnaire (BIPQ) Broadbent et al developed BIPQ [ 32 ] as an assessment tool comprising nine items to assess the impact, disease course, management, treatment, recognition, anxiety, emotional state, understanding and cause of the illness. The scale has eight items rated on an 11-point Likert scale. Higher scores of BIPQ represent more severe negative illness. The Cronbach's alpha coefficient for the present sample was 0.85. 2.5.3 Perceived Social Support Scale (PSSS) Zimet and colleagues developed PSSS [ 33 ]. The scale consists of three dimensions, namely support from family, support from friends, and support from other sources. The scale consists of 12 items with a total score ranging from 12 to 84. Higher scores indicate greater perceived social support. The Cronbach's alpha coefficient for the present sample was 0.98. 2.5.4 Brief Fatigue Inventory-Chinese version (BFI-C) Mendoza et al developed the BFI-C scale [ 34 ] to assess fatigue in patients with cancer. The BFI-C consists of four dimensions with nine items that are scored on a 10-point Likert scale ranging from 0 to 90, with higher scores indicating greater severity of fatigue. The Cronbach alpha coefficient for the present sample was 0.94. 2.5.5 Hospital anxiety and depression scale (HADS) Zigmond AS and Snaith RP developed the Hospital Anxiety and Depression Scale (HADS) [ 35 ]. The HADS consists of two subscales: HADS-A and HADS-D, which assess anxiety and depression, respectively. The Cronbach alpha coefficients for the subscales were 0.78 for depression and 0.74 for anxiety. 2.6 Data collection Study participants were selected based on the eligibility criteria of this study.The survey was conducted when the participants were emotionally and mentally stable and willing to communicate. The researcher (first author) explained the purpose, significance, content, and confidentiality of the questionnaire to the participants before the survey. The participants provided their consent, and the researcher used a unified guide and instructed them face-to-face on how to fill in the questionnaires. For those with low literacy, the researcher read the questionnaire and then recorded and confirmed the answers on the participant’s behalf. All questionnaires were distributed, completed, checked, and recycled on-site. 2.6 Statistical analysis Statistical Package for Social Sciences (SPSS) software version 22.0 was used for the statistical analysis of data. Measurement data were presented as mean ± standard deviation (SD), and enumeration data were presented as frequency and rate. Baseline differences in demographic and medical characteristics between groups were analyzed independently using t-tests or χ2 analysis. Pearson correlation analysis was used to examine the relationship between anxiety, depression, illness perception, cancer-related fatigue, social support, and FCR among young- and middle-aged patients with LC.Stepwise multiple regression analysis was performed to identify the factors affecting FCR in young- and middle-aged patients with LC. The statistical significance was considered at p < 0.05. Results 3.1 Sample characteristics A total of 165 young- and middle-aged adults with LC were included in the study. The mean age was 50.51 ± 7.11 years; 85 (51.5%) were males and 80 (48.5%) were females. In total, 101 patients (61.2%) were in cancer stage IV; 24 (14.5%) had a Karnofsky Performance Scale score ≤ 70; and 112 (62.4%) received combined chemotherapy (Table 2 ). The results of χ2and independent samples t-test showed statistical differences in FoP-Q-SF scores for factors including female ( p < 0.001), duration of disease (p < 0.001), smoking (p < 0.01) ,working status (p < 0.001) and only child ( p < 0.001) (Table 2 ). Table 2 Baseline characteristics of the study population (n = 165) Variables n (%) Average FoP-Q-SF score T/χ 2 P value Age (years) 0.744 0.458 18–45 11 (6.7) 32.45 ± 9.92 46–64 154 (93.3) 29.95 ± 10.81 Sex -11.11 0.000 Male 85 (51.5) 23.29 ± 7.47 Female 80 (48.5) 37.38 ± 8.77 KSP score -1.566 0.119 ≤ 70 24 (14.5) 26.95 ± 8.42 > 70 141 (85.5) 30.65 ± 11.03 Surgery -1.364 0.175 yes 99 (60.0) 29.19 ± 11.04 no 66 (40.0) 31.51 ± 10.21 Disease duration(months) 14.603 0.000 12 80 (48.5) 33.06 ± 9.71 Treatment 2.506 0.085 Chemotherapy 53 (32.1) 28.22 ± 11.07 Combined chemotherapy 112 (62.4) 30.54 ± 10.36 Pathologic stage 0.140 I 24 (14.5) 26.75 ± 10.87 1.849 II 23 (13.9) 28.65 ± 8.53 III 17 (10.3) 27.94 ± 11.58 IV 101 (61.2) 31.62 ± 10.88 Smoking 0.000 Yes 87 (52.7) 25.80 ± 9.72 -6.002 No 78 (47.3) 34.93 ± 9.79 Marital status 0.741 Unmarried 5 (3.0) 33.80 ± 12.39 0.300 Married 152 (92.1) 30.00 ± 10.82 Divorced 8 (4.8) 30.12 ± 8.96 Family cancer history 0.555 Yes 58 (35.2) 29.44 ± 11.01 0.591 No 107 (64.8) 30.48 ± 10.63 Only child 0.000 Yes 50 (30.3) 37.56 ± 11.11 -6.573 No 115 (69.7) 26.88 ± 8.84 Residence 0.306 City 48 (29.1) 29.31 ± 9.54 1.219 Suburban district 51(30.9) 33.80 ± 10.55 countryside 66 (40.0) 29.60 ± 10.59 Education 0.982 <High school 55 (33.3) 29.92 ± 9.67 0.018 High school 86 (52.1) 30.16 ± 11.84 University 24 (14.5) 30.41 ± 9.23 Working status 0.000 Currently working 46 (27.9) 22.36 ± 9.60 66.199 retired 42 (25.5) 24.88 ± 6.18 Not working 29 (17.6) 30.68 ± 3.25 Unemployment after illness 48 (29.1) 41.79 ± 7.24 Family monthly income (RMB) 0.205 8001 25 (15.2) 31.92 ± 11.18 Minoritious Yes 11(66,7) 30.46 ± 11.12 1.089 0.278 No 154(93.3) 28.18 ± 11.06 Religious belief 0.078 Yes 23 (13.9) 33.78 ± 11.08 -1.772 No 142 (86.1) 29.52 ± 10.61 Health insurance 0.322 Employee medical insurance 99 (60.0) 29.23 ± 11.00 1.142 Urban dwellers 49 (29.7) 30.85 ± 9.88 Rural cooperative 17 (10.3) 33.17 ± 11.52 3.2 Prevalence of high FCR The patients' score on the FoP-Q-SF was 30.12 (SD = 10.12). The majority of patients (59, 35.8.%) had high FCR based on the threshold score of ≥ 34.The item with the highest mean was “Worrying about the disease will have negative consequences on the family” (M = 3.07), and the item with the lowest mean was “Being nervous prior to doctor’s appointments or periodic examinations” (M = 2.05). 3.3 Association between high FCR, anxiety, depression, illness perception, fatigue, and social support The results of Pearson correlation analysis showed a significant positive correlation between FoP-Q-SF score and anxiety (r = 0.253, p < 0.01), depression (r = 0.213, p < 0.01), illness illness perception (r = 0.730, p < 0.01), and fatigue (r = 0.721, p < 0.01) in young- and middle-aged patients with LC. However, a negative correlation was observed with the score of social support (r = -0.521, p < 0.01; Table 3 ). Table 3 Correlation analysis of FCR score with anxiety, depression, illness perception, and social support FCR Anxiety Depression Illness Perception Fatigue Social support FCR 1.000 Anxiety 0.253 ** 1.000 Depression 0.213 ** 0.334 ** 1.000 Illness Perception 0.730 ** 0.388 ** 0.311 ** 1.000 Fatigue 0.721 ** 0.334 ** 0.235 ** 0.681 ** 1.000 Social support -0.521 ** -0.257 ** 0.043 -0.297 ** -0.345 ** 1.000 Note: **. The correlation is significant at the 0.01 level (two-tailed). 3.4 Independent factors of high FCR Variables that were statistically significant in univariate analysis and Pearson correlation analysis were subjected to stepwise multivariate regression analysis. The results of multiple regression analysis showed a significant regression equation (F = 83.525, p < 0.001). Illness perception (β = 0.257, p < 0.001), fatigue (β = 0.155, p = 0.002), female (β = 0.185, p < 0.001), only child (β = 0.200, p < 0.001), working status (β = 0.272, p < 0.000), and social support (β = -0.160, p < 0.001) significantly and positively predicted FCR in young- and middle-aged patients with LC.These variables together explained 83.4% of the variance in FCR (Table 4 ). Table 4 Multiple regression analysis of the fear of cancer recurrence score in young and middle-aged patients with LC B SE β t p Anxiety 0.689 1.277 0.021 0.539 0.591 Depression 2.085 1.140 0.067 1.830 0.069 Illness perception 1.796 0.340 0.257 5.281 0.000 Fatigue 0.603 0.188 0.155 3.208 0.002 Social support -1.527 0.361 -0.160 -4.224 0.000 Sex 3.977 1.089 0.185 3.653 0.000 Disease duration 0.517 0.403 0.045 1.282 0.202 Only child 4.666 0.867 0.200 5.384 0.000 Smoking 0.919 0.985 0.043 0.933 0.352 Working status 2.469 0.383 0.272 6.444 0.000 Note: R 2 = 0.844, adjusted R 2 = 0.834, F = 83.525, p < 0.001 Discussion The present study uses SEM to provide novel insight into the determinants of FCR among young and middle-aged LC patients. Multiple linear regression analyses showed that factors in the intrapersonal level including female, illness perception, and fatigue (p < 0.01), and factors in the interpersonal level including only child and social support, and the factor in the social-economic level including working status, were independent predictors of high FCR. We found that 35.8% of young- and middle-aged patients with LC had a high FCR. This was lower than the 68% reported in a meta-analysis [ 17 ], but higher than the FCR prevalence in patients with non-small cell lung carcinoma (NSCLC) in Taiwan (21.6%) [ 9 ]. There is still a lack of consensus on the definition and conceptual model of FCR, and different measures with varying sensitivities and specificities have emerged for detecting the severity of FCR [ 36 ]. This study used the FoP-Q-SF scale, and the 7-item FCR scale developed by Lee et al [ 9 ]. Moreover, compared with mainland China, Taiwan has a relatively higher per capita income, a well-established universal healthcare system, and well-developed and good coverage for hospice care. These macro-policy differences may have an impact on the financial and psychological burden of cancer survivors. female The results show that females are at a high risk of developing FCR, which is consistent with the results of many previous studies [ 16 , 18 , 22 , 29 ]. The trend towards LC incidence at younger age is more pronounced in females.The etiology of the sex differences in FCR is unclear. However, one possible explanation is that females are more likely to have negative psychological conditions. Women are more susceptible to psychological and emotional changes and less able to cope with accidents than men because they are exposed to multiple stressors (e.g. caring for family members while working) [ 22 ].Studies have shown that anxiety and depression are twice as prevalent in females [ 16 ]. Our study showed that LC survivors with higher levels of anxiety and depression were more likely to have experienced FCR. A meta-analysis [ 18 ] also found that patients with high FCR may use more avoidant coping styles and are more likely to experience depression and distress.Considering the high prevalence of anxiety in patients with LC [ 15 ], it is essential to enhance early psychological screening and intervention to prevent FCR,especially in female patients. illness perceptions The present study showed that negative illness perception was significantly associated with high FCR, which corroborates with Lee-Jones et al’s model [ 37 ]. According to their model, the level of FCR is determined by the patient's illness perception through cognitive and emotional processing. For young- and middle-aged patients with LC, illness perception is more sensitive due to disease-related role dysfunction and difficulty in accepting that they have been diagnosed with cancer at a young age. Previous studies [ 38 ] have shown that illness perception is a determinant of quality of life for patients with LC and that when major changes seem to control a person's life, it is crucial to give meaning to events, which can alleviate suffering and improve well-being. Studies [ 39 ] have shown that cognitive behavioral therapy can effectively reduce FCR by improving the rationale of cancer survivors, thereby understanding and appraising disease risk. Recent research [ 40 ] has also shown that daily communication between couples plays a crucial role in the association between illness perception and FCR and that family- or couple-based psychotherapy can be used to alleviate FCR by improving daily communication skills. cancer-related fatigue According to the cognitive-behavioral model of FCR,Illness perception can be triggered by antecedents that include internal/external cues [ 37 ].Symptoms are an important internal trigger for FCR, as they can be a reminder to patients of their physical condition and the likelihood of cancer recurrence [ 9 , 37 , 41 ]. Our study further showed that cancer-related fatigue is a strong FCR predictor. Previous studies have shown that among LC symptoms (e.g., pain, fatigue, nausea/vomiting, dyspnea, and insomnia), fatigue was most correlated with FCR [ 9 ]. A study by Cho et al. [ 42 ] also showed that higher levels of pain and fatigue were associated with higher FCR, which was further related to lower emotional well-being. LC survivors reported more frequent and severe symptoms of cancer-related fatigue than other cancer survivors [ 43 ]. Fatigue is a strong sign of recurrence that leads young- and middle-aged LC survivors to seek reassurance, indicating that symptom-related worry could be an important mechanistic target for survivorship intervention. Therefore, increased education of patients about fatigue management strategies (e.g. mindful awareness, sitting meditation, mindful walking,Tai-Chi,and gentle yoga) [ 44 – 45 ] to improve fatigue symptoms is particularly important for reducing FCR. working status and only child In this study, working status and only child were found to be the predictors of high FCR. Patients who were unemployed after the disease faced more severe FCR. A possible mechanism by which young- and middle-aged adults are a unique age group who bear higher family and financial burden, and this burden is even greater for cancer survivors who are the only children to their parents. Longitudinal studies have shown [ 30 ] that patients with LC who are the breadwinners of their families have higher levels of FCR at 3 and 6 months post surgery. So et al [ 46 ] pointed out that “returning to work” is the main concern of young cancer patients who will experience greater psychological pressure when they are unable to work normally. social support The present study found that LC survivors with higher levels of social support were less likely to experience FCR and social support was an independent protective factor for FCR. Liu et al.[ 22 ] and Chen et al.[ 28 ] also found that social support was an independent protective factor for FCR in patients with LC. The social cognitive processing model of emotional adjustment to cancer suggests that a supportive social environment aids emotional processing and engages adaptive coping strategies.When patients disclose their concerns (e.g., fear of recurrence) to others, their psychological adaptive processes are enhanced if they feel more socially supported. This promotes the adoption of adaptive coping strategies and the progression to a favorable psychological state [ 47 ]. According to SEM, the population from the interpersonal level, including the family, work group, friendship, and medical staff networks, can provide social identity, support, and role definition [ 25 ]. Therefore, it is possible to start with the environment in which the patient lives, especially family, friends, employers, and other social groups, promoting the interpersonal level environment that better meets the patient's needs and thus reducing the level of FCR. Limitations Despite we significant clinical implications, this study has some limitations. Participants were drawn from only one tertiary specialist hospital in Nanjing, limiting its representativeness.There is a need for a further multi-centre, large sample study using validated instruments.Second, this study was a cross-sectional study, which could not dynamically understand the process of FCR trajectory. A longitudinal study could be conducted in the future to explore the developmental course of FCR, which would provide a basis for accurately understanding the timing of psychological interventions and reasonably conducting follow-up visits. Finally, this study is a quantitative study, which cannot capture in-depth information. We can use qualitative interviews to understand patients' knowledge and feelings about FCR and delve into the facilitating and hindering factors of FCR. Despite we significant clinical implications, this study has some limitations. Participants were drawn from only one tertiary specialist hospital in Nanjing, limiting its representativeness.There is a need for a further multi-centre, large sample study using validated instruments.Second, this study was a cross-sectional study, which could not dynamically understand the process of FCR trajectory. A longitudinal study could be conducted in the future to explore the developmental course of FCR, which would provide a basis for accurately understanding the timing of psychological interventions and reasonably conducting follow-up visits. Finally, this study is a quantitative study, which cannot capture in-depth information. We can use qualitative interviews to understand patients' knowledge and feelings about FCR and delve into the facilitating and hindering factors of FCR. Conclusions Using SEM, this study explored the determinants of FCR in young- and middle-aged patients with LC.We suggest screening and early detection of FCR based on the above predictors. These findings suggest that future management strategies for FCR in young- and middle-aged patients with LC should focus on addressing risk factors associated with this condition, with particular attention to controllable factors including illness perceptions,fatigue,social support ,and working status.While factors like female and only child may not be readily modifiable, they can serve as valuable predictors to assist healthcare Declarations Corresponding author: Guanghui XIA; E-mail: [email protected] . providers in recognizing individuals who would gain benefit from closer monitoring and preventive measures. Author Contributions: Qin Wang: Data curation, Writing- Original draft preparation, Software. Guanghui XIA:Conceptualization, Methodology, Writing- Reviewing and Editing. Feng Liu: Validation, Supervision. Xiaoxin Yang: Visualization, Investigation, Supervision. All authors have read and agreed to the published version of the manuscript. Corresponding author: Guanghui XIA; E-mail: [email protected] . Author details: Qin Wang 1,2; Guanghui XIA 1,3; Feng Liu1,2; Xiaoxin Yang1,2. 1.Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing, China 2.Department of thoracic surgery, Nanjing Chest Hospital, Nanjing, China. 3.Department of Nursing, Nanjing Chest Hospital, Nanjing, China Funding: This work was supported by the Special Fund Project for the Development of Health Science and Technology in Nanjing(Grant NO.YKK23148). Ethics statement: This study was conducted after obtaining approval from the Research Ethics Review Committee of Affiliated Nanjing Brain Hospital. (Approval No.2023-KY077-01). All participants provided written informed consent.The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Conflicts of Interest: The authors declare no conflicts of interest. References Zheng RS, Chen R, Han BF, et. [Cancer incidence and mortality in China, 2022]. 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A systematic review and individual participant data meta-analysis. Psychooncology. 2022;31(6):879–892.. Zhang X, Sun D, Qin N, et al. Factors Correlated With Fear of Cancer Recurrence in Cancer Survivors: A Meta-analysis. Cancer Nurs. 2022;45(5):406–415. Meagher BR. Ecologizing Social Psychology: The Physical Environment as a Necessary Constituent of Social Processes. Pers Soc Psychol Rev. 2020;24(1):3–23. Anderson K, Smith A', Diaz A, et al. A Systematic Review of Fear of Cancer Recurrence Among Indigenous and Minority Peoples. Front Psychol. 2021;12:621850. Ashing KT, Cho D, Lai L, et al. Exploring characteristics, predictors, and consequences of fear of cancer recurrence among Asian-American breast cancer survivors. Psychooncology. 2017;26(12):2253–2260. Liu M, Liu L, Zhang S, et al. Fear of cancer recurrence and hope level in patients receiving surgery for non-small cell lung cancer: a study on the mediating role of social support. Support Care Cancer. 2022;30(11):9453–9460. McLeroy KR, Bibeau D, Steckler A, et al. An ecological perspective on health promotion programs. Health Educ Q. 1988;15(4):351–77. Loewenstein K. Parent Psychological Distress in the Neonatal Intensive Care Unit Within the Context of the Social Ecological Model: A Scoping Review. J Am Psychiatr Nurses Assoc. 2018;24(6):495–50 Balducci L. Management of cancer in the elderly. Oncology (Williston Park). 2006;20(2):135–43. Zhou S, Shen C, Che G. [Research Progress of Treatment for NSCLC in Young Patients]. Zhongguo Fei Ai Za Zhi. 2022;25(12):888–894. Chinese. Wang X, Ji X. Sample size estimation in clinical research: from randomized controlled trials to observational studies. Chest. 2020 Chen R, Yang H, Zhang H,et al. Fear of progression among postoperative patients with newly diagnosed lung cancer: a cross-sectional survey in China. BMC Psychol. 2023;11(1):168. doi: 10.1186/s40359-023-01211-5 . PMID: 37217966; PMCID: PMC10201766. Zheng W, Hu M, Liu Y. Social support can alleviate the fear of cancer recurrence in postoperative patients with lung carcinoma. Am J Transl Res. 2022;14(7):4804–4811. PMID: 35958474; PMCID: PMC9360850. Yang X, Li Y, Lin J, et al. Fear of recurrence in postoperative lung cancer patients: Trajectories, influencing factors and impacts on quality of life. J Clin Nurs. 2023. Mehnert A, Herschbach P, Berg P, et al. Fear of progression in breast cancer patients–validation of the short form of the Fear of Progression Questionnaire (FoP-Q-SF). Z Psychosom Med Psychother. 2006;52(3):274–88. Broadbent E, Petrie KJ, Main J, et al. The brief illness perception questionnaire. J Psychosom Res. 2006;60(6):631–7. Zimet GD, Powell SS, Farley GK, et al. Psychometric characteristics of the Multidimensional Scale of Perceived Social Support. J Pers Assess. 1990;55(3–4):610–7. Debnath S, Rueda R, Bansal S, et al. Assessment of fatigue in hemodialysis patients: Performance of the Brief Fatigue Inventory. Gen Hosp Psychiatry. 2021;68:115–117. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand 1983;67:361–70. Thewes, B, Butow P, Zachariae R et al. Fear of cancer recurrence: A systematic literature review of self-report measures. Psychooncology 2012, 21, 571–587. Lee-Jones C, Humphris G, Dixon R, et al. Fear of cancer recurrence–a literature review and proposed cognitive formulation to explain exacerbation of recurrence fears. Psychooncology. 1997;6(2):95–105. Masson N, Dany L, Cannone P, et al. Illness representations and quality of life in French patients suffering from lung cancer. Psychol Health Med. 2020;25(9):1119–1129. Nguyen P, Heisey R, Quenneville C, et al. An examination of depression, anxiety, and fear of recurrence among cancer survivors who participated in a virtual cognitive behavioral therapy (CBT)-based telephone coaching program. Support Care Cancer. 2022;30(9):7323–7332. Xu W, Wang J, Schoebi D. The role of daily couple communication in the relationship between illness representation and fear of cancer recurrence in breast cancer survivors and their spouses. Psychooncology. 2019;28(6):1301–1307. Custers JA, Gielissen MF, de Wilt JH, et al. Towards an evidence-based model of fear of cancer recurrence for breast cancer survivors. J Cancer Surviv. 2017;11(1):41–47. doi: 10.1007/s11764-016-0558-zIF: 3.7 Q1. Epub 2016 Jul 13. PMID: 27412726; PMCID: PMC5266772. Cho D, Chu Q, Lu Q. Associations among physical symptoms, fear of cancer recurrence, and emotional well-being among Chinese American breast cancer survivors: a path model. Support Care Cancer. 2018;26(6):1755–1761. Bade BC, Faiz SA, Ha DM, et al. Cancer-related Fatigue in Lung Cancer: A Research Agenda: An Official American Thoracic Society Research Statement. Am J Respir Crit Care Med.2023;207(5):e6-e28. Hilfiker R, Meichtry A, Eicher M, et al. Exercise and other non-pharmaceutical interventions for cancer-related fatigue in patients during or after cancer treatment: a systematic review incorporating an indirect-comparisons meta-analysis. Br J Sports Med. 2018;52(10):651–658. doi: 10.1136/bjsports-2016-096422 . Epub 2017 May 13. PMID: 28501804; PMCID: PMC5931245. Li J, Li C, Puts M, et al. Effectiveness of mindfulness-based interventions on anxiety, depression, and fatigue in people with lung cancer: A systematic review and meta-analysis. Int J Nurs Stud. 2023;140:104447. doi: 10.1016/j.ijnurstu.2023.104447 . Epub 2023 Jan 30. PMID: 36796118. So N, McDowell LJ, Lu L, et al. The Prevalence and Determinants of Return to Work in Nasopharyngeal Carcinoma Survivors. Int J Radiat Oncol Biol Phys. 2020 106(1):134–145. Mikrut EE, Panjwani AA, Cipollina R, et al. Emotional adjustment among parents of adolescents and young adults with cancer: the influence of social constraints on cognitive processing and fear of recurrence. J Behav Med. 2020;43(2):237–245. doi: 10.1007/s10865-019-00072-x . Epub 2019 Jul 2. PMID: 31267408. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5322961","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":372559772,"identity":"5eac65e0-a2a2-470b-92e5-5fae9a596729","order_by":0,"name":"Qin Wang","email":"","orcid":"","institution":"Affiliated Nanjing Brain Hospital,Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qin","middleName":"","lastName":"Wang","suffix":""},{"id":372559773,"identity":"48ba35ff-70e2-407f-ab4f-a9414760b391","order_by":1,"name":"Guanghui XIA","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAw0lEQVRIiWNgGAWjYFACHgaDDxUScmzs7QeI11I444yNMR/PmQTitXzmbUtLnCfhYECcBoPzaw9u4G07nN4mwZDA8KNiG2EtkjPeJRtInDuc2ybdeICx58xtwlr4Jc6YGRiUAbXIHEhgZmwjQgubxBnzHwlsh9PZJBIMiNPCz99jYHCgLS2BeC2SM3gMDBvO2Bi2AQP5IFF+MTh/xsD4T4WEvHx7+8EHPyqI0MIgkYBgHyBCPRDwE6luFIyCUTAKRjAAABiDPl2hMlMfAAAAAElFTkSuQmCC","orcid":"","institution":"Affiliated Nanjing Brain Hospital,Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Guanghui","middleName":"","lastName":"XIA","suffix":""},{"id":372559774,"identity":"2f3d0ad2-6560-462f-b7aa-aa475aacd63f","order_by":2,"name":"Feng Liu","email":"","orcid":"","institution":"Affiliated Nanjing Brain Hospital,Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Feng","middleName":"","lastName":"Liu","suffix":""},{"id":372559775,"identity":"6d00546e-2bc9-49c2-b0df-f5ca8453f119","order_by":3,"name":"Xiaoxin Yang","email":"","orcid":"","institution":"Affiliated Nanjing Brain Hospital,Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxin","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2024-10-24 05:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5322961/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5322961/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":70211616,"identity":"ff8f114d-72bd-4525-8ddc-dc55a5b8a98c","added_by":"auto","created_at":"2024-11-29 14:39:36","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125213,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eConstruct of the FCR factors based on the SET\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Figure1.tif.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5322961/v1/00ebb9503380b34f10fe7498.jpg"},{"id":71863698,"identity":"aa67982d-0ad8-4c67-a225-8a951e5e7240","added_by":"auto","created_at":"2024-12-19 09:17:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":972324,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5322961/v1/c65c1566-022d-4de2-ad23-df93c90a8143.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Factors associated with high fear of cancer recurrence in young- and middle-aged patients with lung cancer:A cross-sectional study applying the social-ecological model","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLung cancer (LC) is the leading cause of cancer-related mortality in China. Although more common in males and older patients, a trend towards the younger population is observed, particularly among young women [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The incidence and mortality of LC in China increases significantly after the age of 45 years, and patients under 40 are commonly affected [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Further, LC mortality rates among young men and women are the second and third highest, respectively, among other malignant tumor mortality rates [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The age for early LC screening according to the latest Chinese guidelines for diagnosing and treating LC has been lowered from 50 to 45 years [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Young patients with LC achieve better treatment outcomes after receiving surgery, chemotherapy, or novel targeted and immunotherapy, and have relatively longer relapse-free survival, indicating prolonged survival [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite advances in the treatment and prognosis of LC, many survivors are at risk of cancer recurrence. This uncertainty can cause patients to experience fear of cancer recurrence (FCR), including anxiety and worry of progression [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The incidence of FCR in patients is nearly 72% due to the high mortality rates of LC [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Low FCR can be an incentive for patients to adopt healthy behaviors and adhere to treatment [\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, high FCR leads to reduced quality of life, functional decline, psychological distress, and frequent clinic visits [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Young age is the most consistent predictor of an increase in FCR in patients with cancer [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Young patients with LC are a vulnerable population who are the primary support to their families and shoulder more financial and family responsibilities [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. At the same time, the physical dysfunction and social damage due to the disease and treatment may affect their functioning and even lead to discrimination. As a result, young LC survivors are more likely to experience depression and anxiety [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], further exacerbating FCR.\u003c/p\u003e \u003cp\u003eAn important first step in the development of appropriate strategies for the management of FCR among patients is an understanding of the factors associated with it. Previous studies on FCR among young individuals were focused on breast cancer [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, the severity of FCR varies according to cancer type, treatment, clinical course, and prognosis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Meta-analyses have shown that the incidence of FCR is higher in patients with LC than in patients with breast cancer[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Although some studies have focused on patients with LC, these have included a mixed age samples [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In addition, FCR is a multidimensional phenomenon that may be influenced by several factors [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. However, much of the existing research is focused on individuals (e.g., sociodemographic and clinical cancer variables) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Socio-ecological psychology highlights that the natural and social environment can influence the behavior of individuals. If human psychology and behavior are to be understood, they must be studied in the context of socio-ecological systems [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Social factors also affect FCR. For example, there is a significant difference in the mean level of FCR between racial and ethnic groups [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Chinese women have lower levels of FCR than women in other Asian countries [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Moreover, social support reduces FCR[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe socio-ecological model (SEM) views the social environment in which people live as a complete ecosystem and emphasizes that human behavior is influenced by various factors in the system[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The SEM provides new explanations for the development of human behaviors.Exploring FCR from a socio-ecological perspective allows for a more comprehensive and systematic analysis of the factors influencing FCR. Currently, studies are conducted to apply the SEM theory to understand the factors of parental psychological distress in the neonatal intensive care unit (NICU) [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The aim of this study was to assess the prevalence of FCR in young- and middle-aged patients with LC by applying the SEM and to explore the factors influencing FCR.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eA total of 165 young- and middle-aged patients with LC from the largest chest hospital in Nanjing, China, were selected by convenience sampling for this cross-sectional study. All participants were invited to fill in the questionnaires from the 11 October 2022 to the 27 May 2023.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.2 Ethical considerations\u003c/h3\u003e\n\u003cp\u003e The Ethics Committee affiliated with the Nanjing Medical University approved the study (No. 2022-KY066-01), and all participants provided consent forms before data collection.\u003c/p\u003e\n\u003ch3\u003e2.3 Sample and setting\u003c/h3\u003e\n\u003cp\u003eThe National Comprehensive Cancer Network guidelines on geriatric oncology define patients\u0026thinsp;\u0026ge;\u0026thinsp;65 years of age as elderly [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In China, patients with LC between 18 and 45 years are defined as young [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Based on these criteria, this study defined young- and middle-aged patients with LC as those in the 18\u0026ndash;45 years group and 46\u0026ndash;64 years group, respectively. Inclusion criteria were (1) age of 18\u0026ndash;64 years; (2) diagnosis of LC and knowledge of their condition; and (3) ability to complete questionnaires independently or with assistance. Exclusion criteria were (1) presence of malignant fluid; (2) history of other cancer; (3) severe hearing and visual impairment; (4) severe mental and psychological disorders; and (5) presence of severe physical, heart, liver, kidney disease, or disability.\u003c/p\u003e \u003cp\u003eThe sample size for this study was determined using Kendall's principle, which recommends a sample size of 5\u0026ndash;10 times the number of variables [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. This study included 23 variables with a missing data rate of 20%. Therefore, a minimum sample size of 144\u0026ndash;287 cases was required, calculated using the formula (23[\u003cspan additionalcitationids=\"CR6 CR7 CR8 CR9\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]/[1\u0026ndash;20%]). The number of patients in the study was 165, more than the minimum sample size requirement.\u003c/p\u003e\n\u003ch3\u003e2.4 FCR-related independent variables\u003c/h3\u003e\n\u003cp\u003eThe social-ecological mode(SEM) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] involves humans and their living environments and states that individual behavior is affected by many internal and environmental factors, forming intrapersonal,interpersonal,organization,community,and policy levels (Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) .A comprehensive review of the possible predictors of FCR was conducted in young- and middle-aged patients with LC based on a literature review [9\u0026ndash;10 \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR29\" citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] and considering the clinical component of LC.\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eTABLE\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;1: Level of an ecological perspective\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"644\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003eLevel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eDefinition\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003eIntrapersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eIndividuals in a sociological environment that includes individual demographics, health\u0026nbsp;\u003c/p\u003e\n \u003cp\u003econditions,\u0026nbsp;and\u0026nbsp;others\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003eInterpersonal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eSmall-scale environment directly related individuals\u0026apos; family, work group, friendship, and medical staff networks that provide social identity, support, and role definition\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003eOrganization\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eRules, regulations, policies, and informal structures that may constrain or promote recommended behaviors\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003eCommunity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eSocial networks and norms, or standards, which exist formally or informally among individuals, groups, and organizations\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 16.7702%;\"\u003e\n \u003cp\u003ePolicy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 83.2298%;\"\u003e\n \u003cp\u003eOuter\u0026nbsp;environmental\u0026nbsp;factors,\u0026nbsp;such\u0026nbsp;as\u0026nbsp;culture,\u0026nbsp;laws,\u0026nbsp;and\u0026nbsp;policies,\u0026nbsp;which\u0026nbsp;affect\u0026nbsp;individuals\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e \u003cp\u003eTwo researchers descriptively summarized (Y.L., G.H.X) the factors associated with FCR in LC patients and classified these factors into different levels of SEM.The intrapersonal level was based on biological and individual characteristics.At the interpersonal level, factors were classified based on various networks, (e.g., family, friends, work groups, and medical staff).At the social-economic level the factors were classified into living and working conditions.At the community/public policy level, the factors were classified into politics and culture. Consensus on disagreements was attained through in-depth discussions with the third author (X.X.Y)(Fig.\u0026nbsp;1).\u003c/p\u003e \u003cp\u003e \u003cb\u003eFigure 1 Construct of the FCR factors based on the SET\u003c/b\u003e \u003c/p\u003e\n\u003ch3\u003e2.5 Measures\u003c/h3\u003e\n\u003cp\u003e2.5.1 Fear of Progression Questionnaire-Short Form (FoP-Q-SF)\u003c/p\u003e \u003cp\u003eMehnert et al developed the Fear of Progression Questionnaire Short Form (FoP-Q-SF) [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. The instrument consists of 12 items in two dimensions, namely physical health and social family. The items are scored on a scale of 1 to 5, from \"never\" to \"always\". The total scores range from 12 to 60, with higher scores indicating higher levels of FCR. A total score of \u0026ge;\u0026thinsp;34 is the clinically defined threshold [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The Cronbach's alpha coefficient for FoP-Q-SF was 0.866.\u003c/p\u003e \u003cp\u003e2.5.2 Brief Illness Perception Questionnaire (BIPQ)\u003c/p\u003e \u003cp\u003eBroadbent et al developed BIPQ [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] as an assessment tool comprising nine items to assess the impact, disease course, management, treatment, recognition, anxiety, emotional state, understanding and cause of the illness. The scale has eight items rated on an 11-point Likert scale. Higher scores of BIPQ represent more severe negative illness. The Cronbach's alpha coefficient for the present sample was 0.85.\u003c/p\u003e \u003cp\u003e2.5.3 Perceived Social Support Scale (PSSS)\u003c/p\u003e \u003cp\u003eZimet and colleagues developed PSSS [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The scale consists of three dimensions, namely support from family, support from friends, and support from other sources. The scale consists of 12 items with a total score ranging from 12 to 84. Higher scores indicate greater perceived social support. The Cronbach's alpha coefficient for the present sample was 0.98.\u003c/p\u003e \u003cp\u003e2.5.4 Brief Fatigue Inventory-Chinese version (BFI-C)\u003c/p\u003e \u003cp\u003eMendoza et al developed the BFI-C scale [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e] to assess fatigue in patients with cancer. The BFI-C consists of four dimensions with nine items that are scored on a 10-point Likert scale ranging from 0 to 90, with higher scores indicating greater severity of fatigue. The Cronbach alpha coefficient for the present sample was 0.94.\u003c/p\u003e \u003cp\u003e2.5.5 Hospital anxiety and depression scale (HADS)\u003c/p\u003e \u003cp\u003eZigmond AS and Snaith RP developed the Hospital Anxiety and Depression Scale (HADS) [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The HADS consists of two subscales: HADS-A and HADS-D, which assess anxiety and depression, respectively. The Cronbach alpha coefficients for the subscales were 0.78 for depression and 0.74 for anxiety.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Data collection\u003c/h2\u003e \u003cp\u003eStudy participants were selected based on the eligibility criteria of this study.The survey was conducted when the participants were emotionally and mentally stable and willing to communicate. The researcher (first author) explained the purpose, significance, content, and confidentiality of the questionnaire to the participants before the survey. The participants provided their consent, and the researcher used a unified guide and instructed them face-to-face on how to fill in the questionnaires. For those with low literacy, the researcher read the questionnaire and then recorded and confirmed the answers on the participant\u0026rsquo;s behalf. All questionnaires were distributed, completed, checked, and recycled on-site.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e2.6 Statistical analysis\u003c/h3\u003e\n\u003cp\u003eStatistical Package for Social Sciences (SPSS) software version 22.0 was used for the statistical analysis of data. Measurement data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), and enumeration data were presented as frequency and rate. Baseline differences in demographic and medical characteristics between groups were analyzed independently using t-tests or χ2 analysis. Pearson correlation analysis was used to examine the relationship between anxiety, depression, illness perception, cancer-related fatigue, social support, and FCR among young- and middle-aged patients with LC.Stepwise multiple regression analysis was performed to identify the factors affecting FCR in young- and middle-aged patients with LC. The statistical significance was considered at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Sample characteristics\u003c/h2\u003e \u003cp\u003eA total of 165 young- and middle-aged adults with LC were included in the study. The mean age was 50.51 ± 7.11 years; 85 (51.5%) were males and 80 (48.5%) were females. In total, 101 patients (61.2%) were in cancer stage IV; 24 (14.5%) had a Karnofsky Performance Scale score ≤ 70; and 112 (62.4%) received combined chemotherapy (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe results of χ2and independent samples t-test showed statistical differences in FoP-Q-SF scores for factors including female ( p \u0026lt; 0.001), duration of disease (p \u0026lt; 0.001), smoking (p \u0026lt; 0.01) ,working status (p \u0026lt; 0.001) and only child ( p \u0026lt; 0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\"±\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics of the study population (n = 165)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAverage FoP-Q-SF score\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eT/χ\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.458\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18–45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (6.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e32.45 ± 9.92\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e46–64\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (93.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.95 ± 10.81\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-11.11\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85 (51.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e23.29 ± 7.47\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (48.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e37.38 ± 8.77\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKSP score\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.566\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e≤ 70\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e26.95 ± 8.42\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 70\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e141 (85.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.65 ± 11.03\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.364\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (60.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.19 ± 11.04\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (40.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e31.51 ± 10.21\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease duration(months)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.603\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 6\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (38.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e24.90 ± 10.34\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7–12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (12.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e34.80 ± 9.64\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (48.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e33.06 ± 9.71\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTreatment\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.506\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.085\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChemotherapy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e53 (32.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e28.22 ± 11.07\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined chemotherapy\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e112 (62.4)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.54 ± 10.36\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathologic stage\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e26.75 ± 10.87\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.849\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eII\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (13.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e28.65 ± 8.53\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (10.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e27.94 ± 11.58\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (61.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e31.62 ± 10.88\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (52.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e25.80 ± 9.72\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-6.002\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (47.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e34.93 ± 9.79\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.741\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (3.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e33.80 ± 12.39\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.300\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e152 (92.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.00 ± 10.82\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (4.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.12 ± 8.96\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily cancer history\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.555\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e58 (35.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.44 ± 11.01\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e107 (64.8)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.48 ± 10.63\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly child\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (30.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e37.56 ± 11.11\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-6.573\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e115 (69.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e26.88 ± 8.84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResidence\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (29.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.31 ± 9.54\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.219\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSuburban district\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51(30.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e33.80 ± 10.55\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ecountryside\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66 (40.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.60 ± 10.59\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.982\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;High school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (33.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.92 ± 9.67\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86 (52.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.16 ± 11.84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (14.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.41 ± 9.23\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently working\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (27.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e22.36 ± 9.60\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66.199\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eretired\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (25.5)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e24.88 ± 6.18\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot working\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (17.6)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.68 ± 3.25\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployment after illness\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (29.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e41.79 ± 7.24\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFamily monthly income (RMB)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 5000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e110 (66.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.52 ± 11.08\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.599\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5000–8000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30 (18.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e27.13 ± 8.67\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt; 8001\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (15.2)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e31.92 ± 11.18\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinoritious\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11(66,7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.46 ± 11.12\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.089\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.278\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154(93.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e28.18 ± 11.06\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReligious belief\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.078\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (13.9)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e33.78 ± 11.08\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.772\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e142 (86.1)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.52 ± 10.61\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth insurance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.322\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployee medical insurance\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (60.0)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e29.23 ± 11.00\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.142\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban dwellers\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (29.7)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e30.85 ± 9.88\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural cooperative\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (10.3)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\"±\" colname=\"c3\"\u003e \u003cp\u003e33.17 ± 11.52\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Prevalence of high FCR\u003c/h2\u003e \u003cp\u003eThe patients' score on the FoP-Q-SF was 30.12 (SD = 10.12). The majority of patients (59, 35.8.%) had high FCR based on the threshold score of ≥ 34.The item with the highest mean was “Worrying about the disease will have negative consequences on the family” (M = 3.07), and the item with the lowest mean was “Being nervous prior to doctor’s appointments or periodic examinations” (M = 2.05).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Association between high FCR, anxiety, depression, illness perception, fatigue, and social support\u003c/h2\u003e \u003cp\u003eThe results of Pearson correlation analysis showed a significant positive correlation between FoP-Q-SF score and anxiety (r = 0.253, p \u0026lt; 0.01), depression (r = 0.213, p \u0026lt; 0.01), illness illness perception (r = 0.730, p \u0026lt; 0.01), and fatigue (r = 0.721, p \u0026lt; 0.01) in young- and middle-aged patients with LC. However, a negative correlation was observed with the score of social support (r = -0.521, p \u0026lt; 0.01; Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelation analysis of FCR score with anxiety, depression, illness perception, and social support\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFCR\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIllness Perception\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFCR\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.253\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.213\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.334\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness Perception\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.730\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.388\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.311\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.721\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.334\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.235\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.681\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.521\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.257\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.297\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-0.345\u003csup\u003e**\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003eNote: **. The correlation is significant at the 0.01 level (two-tailed).\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e3.4 Independent factors of high FCR\u003c/h2\u003e \u003cp\u003eVariables that were statistically significant in univariate analysis and Pearson correlation analysis were subjected to stepwise multivariate regression analysis. The results of multiple regression analysis showed a significant regression equation (F = 83.525, p \u0026lt; 0.001). Illness perception (β = 0.257, p \u0026lt; 0.001), fatigue (β = 0.155, p = 0.002), female (β = 0.185, p \u0026lt; 0.001), only child (β = 0.200, p \u0026lt; 0.001), working status (β = 0.272, p \u0026lt; 0.000), and social support (β = -0.160, p \u0026lt; 0.001) significantly and positively predicted FCR in young- and middle-aged patients with LC.These variables together explained 83.4% of the variance in FCR (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultiple regression analysis of the fear of cancer recurrence score in young and middle-aged patients with LC\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003et\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.689\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.277\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.021\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.539\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.591\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDepression\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.085\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.140\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.830\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIllness perception\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.796\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.340\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.257\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.281\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFatigue\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.188\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.155\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.208\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial support\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.527\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.361\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.160\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-4.224\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.977\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.089\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.185\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.653\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisease duration\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.403\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.282\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.202\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly child\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.666\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.384\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSmoking\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.919\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.985\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.043\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.933\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.352\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWorking status\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.469\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.272\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.444\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eNote: R\u003csup\u003e2\u003c/sup\u003e = 0.844, adjusted R\u003csup\u003e2\u003c/sup\u003e = 0.834, F = 83.525, p \u0026lt; 0.001\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003c/div\u003e "},{"header":"Discussion","content":"\u003cp\u003eThe present study uses SEM to provide novel insight into the determinants of FCR among young and middle-aged LC patients. Multiple linear regression analyses showed that factors in the intrapersonal level including female, illness perception, and fatigue (p \u0026lt; 0.01), and factors in the interpersonal level including only child and social support, and the factor in the social-economic level including working status, were independent predictors of high FCR.\u003c/p\u003e\u003cp\u003eWe found that 35.8% of young- and middle-aged patients with LC had a high FCR. This was lower than the 68% reported in a meta-analysis [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], but higher than the FCR prevalence in patients with non-small cell lung carcinoma (NSCLC) in Taiwan (21.6%) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. There is still a lack of consensus on the definition and conceptual model of FCR, and different measures with varying sensitivities and specificities have emerged for detecting the severity of FCR [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This study used the FoP-Q-SF scale, and the 7-item FCR scale developed by Lee et al [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, compared with mainland China, Taiwan has a relatively higher per capita income, a well-established universal healthcare system, and well-developed and good coverage for hospice care. These macro-policy differences may have an impact on the financial and psychological burden of cancer survivors.\u003c/p\u003e\u003ch2\u003efemale\u003c/h2\u003e\u003cp\u003eThe results show that females are at a high risk of developing FCR, which is consistent with the results of many previous studies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The trend towards LC incidence at younger age is more pronounced in females.The etiology of the sex differences in FCR is unclear. However, one possible explanation is that females are more likely to have negative psychological conditions. Women are more susceptible to psychological and emotional changes and less able to cope with accidents than men because they are exposed to multiple stressors (e.g. caring for family members while working) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].Studies have shown that anxiety and depression are twice as prevalent in females [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our study showed that LC survivors with higher levels of anxiety and depression were more likely to have experienced FCR. A meta-analysis [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] also found that patients with high FCR may use more avoidant coping styles and are more likely to experience depression and distress.Considering the high prevalence of anxiety in patients with LC [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], it is essential to enhance early psychological screening and intervention to prevent FCR,especially in female patients.\u003c/p\u003e\u003ch2\u003eillness perceptions\u003c/h2\u003e\u003cp\u003eThe present study showed that negative illness perception was significantly associated with high FCR, which corroborates with Lee-Jones et al’s model [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. According to their model, the level of FCR is determined by the patient's illness perception through cognitive and emotional processing. For young- and middle-aged patients with LC, illness perception is more sensitive due to disease-related role dysfunction and difficulty in accepting that they have been diagnosed with cancer at a young age. Previous studies [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] have shown that illness perception is a determinant of quality of life for patients with LC and that when major changes seem to control a person's life, it is crucial to give meaning to events, which can alleviate suffering and improve well-being. Studies [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e] have shown that cognitive behavioral therapy can effectively reduce FCR by improving the rationale of cancer survivors, thereby understanding and appraising disease risk. Recent research [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] has also shown that daily communication between couples plays a crucial role in the association between illness perception and FCR and that family- or couple-based psychotherapy can be used to alleviate FCR by improving daily communication skills.\u003c/p\u003e\u003ch2\u003ecancer-related fatigue\u003c/h2\u003e\u003cp\u003eAccording to the cognitive-behavioral model of FCR,Illness perception can be triggered by antecedents that include internal/external cues [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].Symptoms are an important internal trigger for FCR, as they can be a reminder to patients of their physical condition and the likelihood of cancer recurrence [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Our study further showed that cancer-related fatigue is a strong FCR predictor. Previous studies have shown that among LC symptoms (e.g., pain, fatigue, nausea/vomiting, dyspnea, and insomnia), fatigue was most correlated with FCR [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A study by Cho et al. [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e] also showed that higher levels of pain and fatigue were associated with higher FCR, which was further related to lower emotional well-being. LC survivors reported more frequent and severe symptoms of cancer-related fatigue than other cancer survivors [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Fatigue is a strong sign of recurrence that leads young- and middle-aged LC survivors to seek reassurance, indicating that symptom-related worry could be an important mechanistic target for survivorship intervention. Therefore, increased education of patients about fatigue management strategies (e.g. mindful awareness, sitting meditation, mindful walking,Tai-Chi,and gentle yoga) [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e–\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] to improve fatigue symptoms is particularly important for reducing FCR.\u003c/p\u003e\u003ch2\u003eworking status and only child\u003c/h2\u003e\u003cp\u003eIn this study, working status and only child were found to be the predictors of high FCR. Patients who were unemployed after the disease faced more severe FCR. A possible mechanism by which young- and middle-aged adults are a unique age group who bear higher family and financial burden, and this burden is even greater for cancer survivors who are the only children to their parents. Longitudinal studies have shown [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e] that patients with LC who are the breadwinners of their families have higher levels of FCR at 3 and 6 months post surgery. So et al [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e] pointed out that “returning to work” is the main concern of young cancer patients who will experience greater psychological pressure when they are unable to work normally.\u003c/p\u003e\u003ch2\u003esocial support\u003c/h2\u003e\u003cp\u003eThe present study found that LC survivors with higher levels of social support were less likely to experience FCR and social support was an independent protective factor for FCR. Liu et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] and Chen et al.[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] also found that social support was an independent protective factor for FCR in patients with LC. The social cognitive processing model of emotional adjustment to cancer suggests that a supportive social environment aids emotional processing and engages adaptive coping strategies.When patients disclose their concerns (e.g., fear of recurrence) to others, their psychological adaptive processes are enhanced if they feel more socially supported. This promotes the adoption of adaptive coping strategies and the progression to a favorable psychological state [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. According to SEM, the population from the interpersonal level, including the family, work group, friendship, and medical staff networks, can provide social identity, support, and role definition [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Therefore, it is possible to start with the environment in which the patient lives, especially family, friends, employers, and other social groups, promoting the interpersonal level environment that better meets the patient's needs and thus reducing the level of FCR.\u003c/p\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eDespite we significant clinical implications, this study has some limitations. Participants were drawn from only one tertiary specialist hospital in Nanjing, limiting its representativeness.There is a need for a further multi-centre, large sample study using validated instruments.Second, this study was a cross-sectional study, which could not dynamically understand the process of FCR trajectory. A longitudinal study could be conducted in the future to explore the developmental course of FCR, which would provide a basis for accurately understanding the timing of psychological interventions and reasonably conducting follow-up visits. Finally, this study is a quantitative study, which cannot capture in-depth information. We can use qualitative interviews to understand patients' knowledge and feelings about FCR and delve into the facilitating and hindering factors of FCR.\u003c/p\u003e \u003c/div\u003e\u003cp\u003eDespite we significant clinical implications, this study has some limitations. Participants were drawn from only one tertiary specialist hospital in Nanjing, limiting its representativeness.There is a need for a further multi-centre, large sample study using validated instruments.Second, this study was a cross-sectional study, which could not dynamically understand the process of FCR trajectory. A longitudinal study could be conducted in the future to explore the developmental course of FCR, which would provide a basis for accurately understanding the timing of psychological interventions and reasonably conducting follow-up visits. Finally, this study is a quantitative study, which cannot capture in-depth information. We can use qualitative interviews to understand patients' knowledge and feelings about FCR and delve into the facilitating and hindering factors of FCR.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eUsing SEM, this study explored the determinants of FCR in young- and middle-aged patients with LC.We suggest screening and early detection of FCR based on the above predictors. These findings suggest that future management strategies for FCR in young- and middle-aged patients with LC should focus on addressing risk factors associated with this condition, with particular attention to controllable factors including illness perceptions,fatigue,social support ,and working status.While factors like female and only child may not be readily modifiable, they can serve as valuable predictors to assist healthcare\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCorresponding author:\u0026nbsp;\u003c/strong\u003eGuanghui XIA;\u0026nbsp;E-mail:[email protected].\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;providers in recognizing individuals who would gain benefit from closer monitoring and preventive measures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u003c/strong\u003e Qin Wang: Data curation, Writing- Original draft preparation, Software. \u0026nbsp;Guanghui XIA:Conceptualization, Methodology, Writing- Reviewing and Editing. Feng Liu: Validation, Supervision. Xiaoxin Yang: Visualization, Investigation, Supervision. All authors have read and agreed to the published version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author:\u0026nbsp;\u003c/strong\u003eGuanghui XIA;\u0026nbsp;E-mail:[email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details:\u003c/strong\u003eQin Wang 1,2; Guanghui XIA 1,3; Feng Liu1,2;\u0026nbsp;Xiaoxin Yang1,2.\u003cbr\u003e\u0026nbsp;1.Affiliated Nanjing Brain Hospital, Nanjing Medical University, Nanjing, China\u003c/p\u003e\n\u003cp\u003e2.Department of thoracic surgery, Nanjing Chest Hospital, Nanjing, China.\u003cbr\u003e\u0026nbsp;3.Department of Nursing, Nanjing Chest Hospital, Nanjing, China\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003eThis work was supported by the Special Fund Project for the Development of\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealth Science and Technology in Nanjing(Grant NO.YKK23148).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics statement:\u003c/strong\u003eThis study was conducted after obtaining approval from the Research Ethics Review Committee of \u0026nbsp;Affiliated Nanjing Brain Hospital. (Approval No.2023-KY077-01). All participants provided written informed consent.The study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest:\u0026nbsp;\u003c/strong\u003eThe authors declare no conflicts of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZheng RS, Chen R, Han BF, et. [Cancer incidence and mortality in China, 2022]. Zhonghua Zhong Liu Za Zhi. 2024;46(3):221\u0026ndash;231. Chinese.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShi J, Li D, Liang D, et al. Epidemiology and prognosis in young lung cancer patients aged under 45 years old in northern China. Sci Rep. 2021;11(1):6817.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZheng RS, Zhang SW, Sun KX, et al. [Cancer statistics in China, 2016]. Zhonghua Zhong Liu Za Zhi. 2023;45(3):212\u0026ndash;220. 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PMID: 31267408.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Young- and Middle-Aged, Lung Cancer, Fear of Cancer Recurrence, Social Ecological Model, Psycho-Oncology, Risk Factors","lastPublishedDoi":"10.21203/rs.3.rs-5322961/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5322961/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo identify the factors associated with FCR in young- and middle-aged patients with lung cancer (LC) by applying the social-ecological mode through a cross-sectional study design.\u003c/p\u003e\u003ch2\u003eMethods A total of 16\u003c/h2\u003e \u003cp\u003e5 patients aged 18\u0026ndash;64 years at diagnosis, were recruited to completed the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), Brief Illness Perception Questionnaire, Perceived Social Support Scale, Brief Fatigue Inventory, and Hospital Anxiety and Depression scale. Self-reported questionnaires and electronic medical records were used for collecting sociodemographic and clinical variables.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe mean FoP-Q-SF score was 30.12\u0026thinsp;\u0026plusmn;\u0026thinsp;10.12; 59 patients (35.8%) had high FCR as indicated by a score of \u0026ge;\u0026thinsp;34. Multiple linear regression analyses showed that factors in the intrapersonal level including female ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), illness perception ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and fatigue (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and factors in the interpersonal level including only child ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.01) and social support (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01), and the factor in the social-economic level including working status( p\u0026thinsp;\u0026lt;\u0026thinsp;0.000), were independent predictors of high FCR.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eMultiple factors influence FCR in young- and middle-aged patients with LC.We suggest screening and early detection of FCR based on the above predictors. Meanwhile,multidimensional perspectives, including intrapersonal, interpersonal, and social-economic levels, should be used to develop comprehensive FCR management strategies.\u003c/p\u003e","manuscriptTitle":"Factors associated with high fear of cancer recurrence in young- and middle-aged patients with lung cancer:A cross-sectional study applying the social-ecological model","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-29 14:39:32","doi":"10.21203/rs.3.rs-5322961/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6604c85a-67bb-404c-8e8f-edd04228b6a5","owner":[],"postedDate":"November 29th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-19T09:09:13+00:00","versionOfRecord":[],"versionCreatedAt":"2024-11-29 14:39:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5322961","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5322961","identity":"rs-5322961","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}