Fear of Cancer Recurrence and Coping in Young Breast Cancer Survivors: A Secondary Analysis

ABSTRACT

Background and Purpose

Fear of cancer recurrence (FCR) is a disruptive concern among young breast cancer survivors (YBCS). Although coping strategies may help mitigate FCR, coping in YBCS remains understudied. This study examined associations between FCR and coping among YBCS and explored whether coping patterns varied across sociodemographic characteristics.

Methods

This cross‐sectional secondary analysis used baseline data from a phase III randomized controlled trial. A purposive sample of 89 post‐treatment YBCS was recruited from the Midwestern US between 2021 and 2023 to complete a self‐reported survey to assess FCR, coping, mental health, and sociodemographic characteristics. Multiple linear regression and partial correlation analyses were performed to examine the associations between coping and FCR.

Results

Greater FCR was associated with avoidant coping (p = 0.0003). Emotion‐focused coping was more common among Black than White YBCS (p = 0.0011) and among those experiencing financial strain (p = 0.0024). Better mental health was associated with less avoidant coping (p = < 0.0001).

Conclusions

Greater FCR was associated with avoidant coping and poorer mental health. Longitudinal assessment of FCR and coping may help identify YBCS who could benefit from supportive interventions during survivorship.

Trial Registration

Clinical Trial Registration Number: NCT05364450

1. Background

In 2026, approximately 17% of breast cancer diagnoses will occur in young women (those diagnosed before 45 years of age) [1]. In this age group, breast cancer is often more aggressive, linked to hereditary mutations, and diagnosed at a later stage [1, 2, 3], but significant advances in cancer treatment mean that young breast cancer survivors (YBCS) are now expected to live long lives. However, this longevity can create psychological challenges to survivorship, including fear of cancer recurrence (FCR) [3, 4, 5, 6, 7]. Defined as the persistent worry or concern that cancer will return, FCR can occur and persist throughout survivorship [8]. In a large meta‐analysis of breast cancer survivors, up to 50% of women were found to experience some level of fear about cancer returning [9]. FCR manifests through intrusive thoughts, hypervigilance in checking for physical symptoms, or avoidance of medical follow‐ups [8, 10]. While FCR threatens long‐term quality of life in survivors of all ages, it is particularly prevalent in young women [3, 11].

Adaptive coping strategies that promote psychological resilience are vital for FCR management, while maladaptive coping diminishes quality of life and contributes to chronic anxiety, post‐traumatic stress, and depression in cancer survivors [8, 10]. Problem‐focused coping is an adaptive strategy that improves mental well‐being by managing FCR through identifying and taking action to reduce stressors [12]. Emotion‐focused coping aims to manage, regulate, or reduce negative emotional reactions caused by FCR [13] using techniques like mindfulness meditation. However, not all emotion‐focused coping strategies are adaptive. Maladaptive emotional coping with FCR includes social isolation and denial [10, 11]. Avoidant coping is also a maladaptive strategy characterized by cognitive and behavioral disengagement to distract from, rather than manage, FCR. While offering short‐term distress reduction, these coping efforts often fail, allowing unwanted feelings to resurface over time [10, 12].

While research has identified adaptive and maladaptive coping mechanisms for FCR in breast cancer survivors of all ages [14, 15, 16, 17], coping remains poorly understood among YBCS who navigate cancer‐related fear alongside milestones such as the establishment of careers, monogamous relationships, and motherhood. Early‐onset cancer is increasing in young women and predicted to rise over the next decade [18]. Understanding how YBCS cope with FCR allows clinicians to support the successful management of FCR throughout survivorship in this population. We aimed to investigate the relationship between FCR and coping among YBCS diagnosed with breast cancer before the age of 45 and explore the extent to which coping patterns varied by sociodemographic characteristics, including race and income perception, which we defined as the subjective interpretation of an individual's financial stability.

2. Methods

2.1. Study Design

This cross‐sectional secondary analysis is reported in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [19]. We used a subset of baseline data from a phase III RCT testing the impact of acceptance and commitment therapy (ACT) for breast cancer survivors with clinically significant FCR (R01CA255480, PI: Johns; Clinical Trial Registration Number NCT05364450). To examine coping in YBCS experiencing FCR, we collected data on FCR, coping, and mental health from a self‐administered baseline survey completed prior to randomization. Participants were recruited from the Midwestern United States between 2021 and 2023, after receiving IRB approval. Recruitment occurred from five clinical sites and the broader community, where study information was distributed to community organizations and at cancer‐related events.

2.2. Sample

The parent RCT consisted of a cohort of 384 breast cancer survivors ages 18 years and older; however, to address study aims, we focused on a subsample of YBCS diagnosed before age 45, per the Centers for Disease Control and Prevention's definition of a YBCS [2]. Of the 256 YBCS approached for the parent RCT, 52 could not be contacted, 66 refused screening, 3 were eligible but refused to participate, and 46 were found to be ineligible to participate. Thus, our subsample consisted of 89 YBCS (see Appendix 1). Inclusion criteria were as follows: (1) women aged ≥ 18 to < 45 years of age at breast cancer diagnosis, (2) stage I‐IIIA breast cancer without evidence of distant disease at study entry, (3) completion of cancer treatment ≤ 5 years prior to study enrollment (ongoing endocrine therapy was allowed), (4) clinically significant FCR (FCR‐7 score ≥ 17) at screening, and (5) ability to speak and read English. Exclusion criteria included: (1) previous breast cancer diagnosis, (2) comorbidities that would impair trial participation (e.g., dementia, severe depressive symptoms PHQ‐2 score ≥ 5 [20] at screening, active substance abuse). Notably, women in active cancer treatment and/or cancer stage greater than IIIA were ineligible, as FCR may be experienced differently in the setting of a new or progressing or more advanced stage cancer diagnosis.

2.3. Data Collection

Participants completed a one‐time, self‐administered, baseline survey including demographic items and medical history, clinical variables, and patient‐reported outcome measures surrounding FCR, coping, and mental health. All participants completed surveys online via a Research Electronic Data Capture (REDCap) survey link received through email. For this study, data were collected prior to randomization to assess coping strategies and FCR at baseline.

2.4. Instruments/Measures

FCR‐7 : A 7‐item measure, the Fear of Cancer Recurrence‐7, assesses anxiety, worry, and strong feelings associated with cancer recurrence, coupled with items assessing cognitive and behavioral responses to FCR on 5‐point Likert scales and a single FCR interference item on a 0–10 scale. Higher scores indicate greater FCR [21].

Brief COPE : This 28‐item measure assesses the frequency of coping behaviors using a 4‐point Likert scale. The measure comprises 14 two‐item subscales that can be grouped into three higher‐order coping domains. Avoidant coping includes self‐distraction, denial, substance use, behavioral disengagement, and self‐blame. Emotion‐focused coping includes the use of emotional support, venting, positive reframing, acceptance, religion, and humor. Problem‐focused coping includes active coping, planning, and the use of instrumental support. Mean scores are calculated for each higher‐order domain, with higher scores indicating greater use of the corresponding coping strategies. The Brief COPE assesses the extent to which specific coping strategies are used but does not categorize strategies as inherently adaptive or maladaptive [22].

PROMIS Global Health : This 10‐item measure assesses mental and physical well‐being, using a 5‐point Likert scale with higher scores indicative of better physical and mental health [23].

2.5. Data Analysis

Patient characteristics at baseline and age at breast cancer diagnosis were described by mean ± standard deviation (SD) on continuous variables or relative frequency by percent on categorical variables. Because of the sample distribution, some racial categories were combined to enable analysis, resulting in small subgroup sizes. Variable associations were then assessed by multiple linear regression between coping strategies and FCR or PROMIS Global Health, adjusted by age at breast cancer diagnosis and race. T scores were calculated from raw data on the PROMIS Global Health measure. Assumptions of linear regression were reassessed. Partial Spearman's $\rho$ correlation [24] was employed to describe covariate‐adjusted association when linear regression assumptions were unmet. Effect sizes were characterized by Cohen's d [25, 26] comparing outcome mean differences across racial groups before and after adjustment for other covariates, for which adjusted means were calculated based on least squares estimation without requiring normality. Two‐sided p‐value < 0.05 was considered statistically significant; we calculated a 95% confidence interval (CI), and all analyses were conducted using SAS 9.4.

Descriptive statistics for items such as treatment timeline, relationship status, and education used N = 89 (See Table 1). Models used N = 88 or 85 to account for one participant with missing race data, one participant missing income perception, and three participants with incomplete FCR‐7 data. FCR‐7 scores were considered missing if any of the seven items were not complete, and those subjects were excluded from the model if FCR was adjusted for. No missingness was noted on PROMIS global scores or Brief COPE scores.

TABLE 1.

Sample demographics.

Category	N	Mean (SD) or %
Age at breast cancer diagnosis	89	38.9 years (±3.8)
Age of sample at baseline	89	41.7 years (±3.8)
Race
White	72	81.8%
Black or African American	10	11.4%
Other/Multiracial	6	6.8%
Ethnicity
Hispanic or Latina	4	4.5%
Non‐Hispanic or Latina	84	95.5%
Relationship Status
Single	22	24.7%
Living with a partner	64	71.9%
Separated/Widowed	3	3.4%
Household Income
<$50,000	17	19.1%
$50,000 to $99,999	29	32.6%
$100,000+	43	48.3%
Income Perception
Do not have enough to make ends meet	5	5.7%
Have just enough to make ends meet	27	30.7%
Comfortable	56	63.6%
Education
Below a bachelor's degree	27	30.2%
Bachelor's degree	30	33.7%
Graduate degree or higher	32	36.0%
Employment
Full time	58	65.2%
Part time	10	11.2%
Self‐employed	7	7.9%
Other	14	15.7%
Completed Breast Cancer Treatment
< 2 years ago	56	62.9%
2–5 years ago	33	37.1%
Do Children Currently Live with You?
Yes	64	71.9%
No	25	28.1%

Note: For Race, Ethnicity, and Income Perception, N = 88 due to one non‐respondent.

3. Results

The sample consisted of 89 early‐stage (I–IIIA) YBCS who had completed active treatment within the past five years of eligibility screening. Mean age at breast cancer diagnosis was 38.9 years (SD±3.8), with 62.9% of participants having completed breast cancer treatment within the previous two years of study start. The majority of YBCS in the sample were white (81.8%), partnered (71.9%), and college educated (70.5%) (see Table 1).

Several significant associations were observed among coping strategies, FCR, mental health, and selected sociodemographic characteristics in YBCS. When adjusted by age at diagnosis and race, avoidant coping was significantly associated with increased FCR among YBCSs (partial Spearman's $\rho$= 0.3508, p = 0.0012). Avoidant coping was also significantly negatively associated with positive mental health (partial Spearman's $\rho$ = −0.4015, p = 0.0001) after adjusting for age at diagnosis and race. When examining coping strategies, we also observed differences in coping by race. Table 2 presents the unadjusted and adjusted effect sizes by Cohen's d for outcome mean differences across the sociodemographic variables of race and income perception. After adjusting for FCR and age at diagnosis, White YBCSs were less likely to use emotion‐focused coping than Black YBCSs (adjusted means (95% CI): 2.219 (2.118, 2.319) White vs. 2.730 (2.448, 3.013) Black, p = 0.0011; adjusted Cohen's d = 1.214). Similarly, Black YBCSs also employed avoidant coping (partial Spearman's $\rho$= 0.2865, p = 0.0115; adjusted Cohen's d = 1.056) significantly more than White YBCSs after adjusting for FCR and age at diagnosis. After adjusting for FCR and age at diagnosis, YBCS with just enough income to make ends meet were more likely to use emotion‐focused coping than YBCS with a comfortable income (adjusted means (95% CI): 2.181 (2.048, 2.314) comfortable vs. 2.284 (2.104, 2.464) have just enough to make ends meet, p = 0.0024; adjusted Cohen's d = 0.210).

TABLE 2.

Effect sizes comparing outcomes across sociodemographic variables. Before/after adjustment for other covariates via multiple linear regression or partial correlation.

Outcome	Socio‐demographic variable	Group	Adjusted means	Adjusted SD	ANCOVA/Partial Spearman's ρ p‐value	Adjusted Cohen's d'	Unadjusted Cohen's d'
Emotional Coping adjusted by age at diagnosis and FCR	Race	Black (n = 9)	2.730	0.433	0.0011	1.214	1.167
	Race	Multiracial (n = 6)	2.144	0.427	0.6790	−0.177	−0.195
	Race	White (n = 70)	2.219	0.428	REFERENCE
Emotional Coping adjusted by age at diagnosis and PROMIS Mental Score	Race	Black (n = 10)	2.785	0.431	0.0002	1.343	1.271
	Race	Multiracial (n = 6)	2.142	0.426	0.6584	−0.190	−0.206
	Race	White (n = 72)	2.222	0.427	REFERENCE
Avoidant Coping adjusted by age at diagnosis and FCR	Race	Black (n = 9)	2.101	0.420	0.0115	1.056	1.076
	Race	Multiracial (n = 6)	1.692	0.415	0.7565	0.131	0.067
	Race	White (n = 70)	1.638	0.415	REFERENCE
Avoidant Coping adjusted by age at diagnosis and PROMIS Mental Score	Race	Black (n = 10)	2.083	0.409	0.0084	1.021	0.995
	Race	Multiracial (n = 6)	1.688	0.405	0.6918	0.116	0.055
	Race	White (n = 72)	1.641	0.405	REFERENCE
Emotional Coping adjusted by age at diagnosis and FCR	Income Perception	Do not have enough to make ends meet (n = 5)	2.875	0.464	0.3900	1.410	1.295
	Income Perception	Have just enough to make ends meet (n = 27)	2.284	0.477	0.0024	0.210	0.045
	Income Perception	Comfortable (n = 53)	2.181	0.494	REFERENCE

Note: Due to missing data (Race, n = 1; Income Perception, n = 1; FCR‐7, n = 3), sample sizes decrease in adjusted models.

Abbreviations: FCR, Fear of Cancer Recurrence; SD, standard deviation.

4. Discussion

This observational study examined the relationship between FCR and coping among YBCS with clinically significant FCR, a population at elevated risk for long‐term psychological distress. Several key findings emerged. First, greater use of avoidant coping was associated with higher levels of FCR and poorer mental health. Second, racial differences in coping patterns were observed, with Black YBCS reporting greater use of both avoidant and emotion‐focused coping compared to White YBCS. Finally, YBCS facing financial strain used emotion‐focused coping more than those who were financially secure. Together, these findings provide insight into how coping processes may contribute to the persistence of distress in this population and highlight potential targets for intervention.

The observed association between avoidant coping and both higher FCR and poorer mental health is consistent with prior research in broader cancer populations, where avoidance has been linked to increased psychological distress and poorer adjustment [15, 27, 28]. Avoidant coping may provide short‐term emotional relief but can reinforce long‐term distress by limiting opportunities for emotional processing and adaptive engagement. In the context of YBCS, who often face ongoing developmental and life‐stage demands, reliance on avoidant coping may further complicate adjustment and interfere with sustained psychological well‐being.

Notably, racial differences in coping patterns warrant careful interpretation and further investigation. Consistent with prior work [29], Black YBCS in this study reported greater use of avoidant coping compared to White YBCS. At the same time, they also reported higher levels of emotion‐focused coping. These findings suggest that coping among Black survivors may be more complex and multifaceted than dichotomous classifications of adaptive vs. maladaptive strategies allow. Emotion‐focused coping was also used more frequently in YBCS reporting financial strain. Although financial toxicity is a well‐documented contributor to distress, including FCR, among cancer survivors, the role of emotion‐focused coping in helping YBCS manage financial strain remains unclear [7, 30]. The Brief COPE does not distinguish between adaptive and maladaptive forms of emotion‐focused coping, and it is therefore unclear whether the strategies reported in this study were beneficial or potentially counterproductive. It is also possible that structural, cultural, and contextual factors, including access to care, financial strain, stigma, and culturally shaped coping norms, may influence coping patterns and should be considered in future research.

These findings have direct implications for the development of future intervention studies examining coping in YBCS. Both FCR and poorer mental health outcomes appeared associated with avoidant coping. This may be a particularly relevant and potentially modifiable intervention target to explore in future studies. Interventions that target avoidance and promote more adaptive coping processes, such as acceptance‐based approaches, may be especially beneficial for YBCS struggling with FCR [31, 32]. Acceptance and Commitment Therapy (ACT), which focuses on reducing experiential avoidance and increasing psychological flexibility, may offer a promising framework for addressing FCR in this population [33]. By helping individuals engage with difficult thoughts and emotions while pursuing meaningful activities, ACT‐based interventions may reduce distress and improve long‐term adjustment.

4.1. Clinical Implications

These findings underscore the importance of integrating psychosocial assessment into survivorship care beyond the immediate post‐treatment period. Many YBCS experience ongoing psychological challenges, including persistent FCR, that may not be routinely assessed in standard follow‐up care. FCR can be efficiently identified in clinical settings using brief screening approaches, including a single‐item measure [34] or other validated short‐form instruments such as the FCR‐4, FCR‐7, or FCRI‐SF [32, 35]. While longer measures may offer stronger psychometric precision, shorter tools may enhance feasibility and facilitate routine integration of FCR screening into survivorship care. Incorporating regular screening for FCR and coping strategies into survivorship visits may help identify individuals at risk for maladaptive coping and declining mental health.

At the same time, these findings support a shift toward more personalized and proactive models of survivorship care. Rather than relying solely on survivors to seek support, clinicians can normalize discussions of FCR and coping, assess coping strategies in a nuanced way, and offer tailored referrals to evidence‐based interventions when appropriate. Importantly, the goal is not to replace survivors' preferred coping approaches, but to ensure that those experiencing distress have access to tools that support adaptive coping and long‐term well‐being.

4.2. Limitations

This study has several limitations. The relatively small and demographically homogeneous sample, particularly within racial subgroups, may limit statistical power and generalizability. Future studies should include larger and more diverse samples to better understand how coping processes vary across populations. In addition, the cross‐sectional design precludes conclusions about causality or the directionality of relationships between FCR and coping. Longitudinal research is needed to examine how coping strategies influence the trajectory and persistence of FCR over time.

The use of the Brief COPE also limits interpretation, as it does not differentiate between adaptive and maladaptive forms of emotion‐focused coping. Future research should incorporate more nuanced measures or qualitative approaches to better characterize coping processes in YBCS. Finally, this study focused on survivors with clinically significant FCR, which may limit generalizability to those with lower levels of cancer‐related fear.

5. Conclusion

This study demonstrates that avoidant coping is strongly associated with greater FCR and poorer mental health among YBCS, highlighting it as a key target for intervention. While emotion‐focused coping was more frequently reported among Black YBCS and YBCS experiencing financial strain, its role remains unclear and warrants further investigation. These findings suggest that improving coping processes, particularly reducing avoidance, may be critical for enhancing psychological outcomes in this population. Integrating coping assessment and evidence‐based interventions into survivorship care may help support the long‐term well‐being of YBCS.

Author Contributions

Christa Torrisi: conceptualization, writing – original draft, investigation, writing – review and editing. Yang Li: formal analysis, writing – review and editing, methodology. Shelley A. Johns: writing – review and editing, funding acquisition, investigation, supervision, methodology, conceptualization. Matthew E. Hays: methodology, formal analysis, writing – review and editing.

Funding

This work was supported by the National Institutes of Health under Award T32CA117865 and the National Cancer Institute under Award R01CA255480.

Ethics Statement

This study was approved by the Indiana University Institutional Review Board (protocol approval no. 11066) on 4/20/2021.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix 1 STROBE flow diagram of participant recruitment and inclusion.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.