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Confirmatory Factor Analysis of the Fear of Cancer Recurrence Scale-7 in Patients Following Completion of Lung Cancer Treatment with Curative Intent

This study validates the Fear of Cancer Recurrence Scale-7 (FCR-7) as a reliable and unidimensional screening tool for assessing fear of recurrence and its associations with psychosocial well-being among U.S. patients following curative lung cancer treatment.

Original authors: Elisabeth C. Henley, Maia A. Chester, Jessica Whitman, Sierra Bainter, Daniel L. Hall, Joseph A. Greer, Areej El-Jawahri, Frank J. Penedo, Jennifer S. Temel, Lara Traeger

Published 2026-06-30

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CC BY 4.0

Original authors: Elisabeth C. Henley, Maia A. Chester, Jessica Whitman, Sierra Bainter, Daniel L. Hall, Joseph A. Greer, Areej El-Jawahri, Frank J. Penedo, Jennifer S. Temel, Lara Traeger

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine you have just finished a long, grueling marathon. You've crossed the finish line, but your legs are still shaking, and your mind is racing with one nagging thought: "What if I trip again? What if the race isn't actually over?"

For many people who have beaten cancer, especially lung cancer, that nagging thought is called Fear of Cancer Recurrence (FCR). It's the worry that the disease will come back.

This research paper is like a quality control check on a specific "worry meter" called the Fear of Cancer Recurrence Scale-7 (FCR-7). The researchers wanted to see if this 7-question tool works well for lung cancer survivors in the United States, right after they finish their treatment.

Here is the breakdown of what they did and found, using simple analogies:

1. The Goal: Finding the Right Ruler

The researchers knew that lung cancer survivors are at high risk for this fear because the disease is serious and often comes back. They needed a quick, reliable way to measure how scared a patient is. They chose the FCR-7, a short questionnaire with just seven questions.

Think of the FCR-7 as a thermometer for fear. Just as a doctor needs a thermometer that gives an accurate reading of a fever, psychologists need a tool that gives an accurate reading of fear. The question was: Does this specific thermometer work for lung cancer patients?

2. The Experiment: Testing the Thermometer

The team looked at data from 109 lung cancer patients who had just finished their curative treatment (like chemotherapy or surgery) within the last three weeks. These patients were mostly older adults (average age 69) and mostly White.

They asked these patients to fill out the 7-question fear survey, along with other surveys about:

How sad or anxious they felt (Psychological distress).
How lonely they felt.
How much pain or physical symptoms they had.
How much they felt supported by friends and family.
How good their overall quality of life was.

3. The "Tuning" Process (The Results)

When the researchers first ran the numbers, the "thermometer" wasn't quite perfect. It was like a scale that was slightly off-kilter.

The Glitch: Two of the questions were essentially asking the same thing in slightly different ways. One asked, "Are you afraid?" and the other asked, "Are you worried?" Because these two feelings are so closely linked, the math got a little messy when the researchers tried to treat them as separate items.
The Fix: The researchers made a small adjustment. They allowed those two specific questions to "talk" to each other in the math model (a statistical tweak called a "correlated residual").
The Result: Once they made that small fix, the model fit perfectly. It turned out the fear of recurrence is indeed a single, unified concept (like a single beam of light, not a rainbow of different colors). The tool proved to be very reliable (consistent) and valid (it measured what it was supposed to).

4. What the Fear Meter Revealed

Once the tool was calibrated, the researchers looked at what the "fear readings" told them about the patients' lives. The results were like a map showing how fear connects to other parts of life:

High Fear = High Distress: Patients who scored high on the fear scale also reported feeling much more anxious and depressed.
High Fear = Physical Pain: Those with high fear also reported more physical symptoms and body aches.
High Fear = Lower Quality of Life: The more they feared the cancer returning, the less they enjoyed their daily lives.
High Fear = Loneliness: High fear was linked to feeling more alone and having less support from others.

5. The Bottom Line

The study concludes that the FCR-7 is a solid, trustworthy tool for checking in on lung cancer survivors in the U.S. right after they finish treatment.

It confirmed that for these patients, fear of the cancer coming back is a real, single thing that can be measured with just seven questions. Furthermore, it showed that when this fear is high, it doesn't just stay in the mind; it drags down a person's mood, their physical comfort, and their sense of connection with others.

In short: The researchers built a reliable "fear detector" for lung cancer survivors and found that when the detector goes off, it signals that the patient needs help with their overall well-being, not just their cancer worry.

Technical Summary: Confirmatory Factor Analysis of the Fear of Cancer Recurrence Scale-7 in Lung Cancer Survivors

Problem Statement
Fear of cancer recurrence (FCR) is a prevalent and distressing psychological challenge for cancer survivors, particularly those with lung cancer, a disease characterized by high recurrence risks (50–75% for curative-intent treatments). While the Fear of Cancer Recurrence Scale-7 (FCR-7) has been validated in various international and cancer-specific populations (e.g., breast, colorectal), its psychometric properties had not been rigorously evaluated in U.S. patients with lung cancer, specifically during the immediate post-treatment survivorship phase. The lack of brief, validated screening tools limits the early identification of FCR, which is critical given its association with diminished quality of life (QoL), psychological distress, and adverse health behaviors.

Methodology
This study conducted a secondary analysis of baseline data from a randomized controlled trial involving 109 U.S. patients with lung cancer who had completed curative-intent treatment within the preceding three weeks. The sample was predominantly non-Hispanic White (96%) and female (55%), with a mean age of 68.9 years.

The researchers employed Confirmatory Factor Analysis (CFA) and Structural Equation Modeling (SEM) using R (version 4.5.2) and the lavaan package with a maximum likelihood robust (MLR) estimator. Missing data were handled via Full-Information Maximum Likelihood (FIML). The analytic plan proceeded in three stages:

Model 1: Tested the theorized single-factor structure of the FCR-7 with seven items.
Model 2: Modified Model 1 by adding a correlated residual between Items 1 and 2, which theoretically captured overlapping content regarding fear and worry.
Model 3: Extended Model 2 to evaluate construct validity by regressing the latent FCR factor against exogenous variables: psychological distress (HADS), general QoL (FACT-G), lung-specific physical symptoms (FACT-LCS), loneliness (CELM), and social support (MSPSS).

Model fit was assessed using $\chi^2$ , Comparative Fit Index (CFI), Tucker-Lewis Index (TLI), Root Mean Square Error of Approximation (RMSEA), and Standardized Root Mean Square Residual (SRMR).

Key Results

Factor Structure: The initial single-factor model (Model 1) demonstrated poor fit ( $\chi^2(14) = 72.42, p < .001$ ; CFI = .897; RMSEA = .196). Local fit diagnostics revealed a substantial residual correlation between Item 1 ("I am afraid my cancer may return") and Item 2 ("I am worried or anxious about the possibility of cancer recurrence").
Revised Model: Model 2, which included a correlated residual between Items 1 and 2, showed a significant improvement in fit ( $\Delta\chi^2(1) = 26.16, p < .001$ ), achieving acceptable indices (CFI = .960; TLI = .936; RMSEA = .126). This model retained a unidimensional structure with high composite reliability ( $\omega = .905$ ). Item 6 ("I examine myself to see if I have physical signs of cancer") showed the weakest loading ( $\lambda = .44$ ) but remained acceptable.
Construct Validity: In Model 3, the latent FCR factor demonstrated strong and theoretically coherent associations with psychosocial variables. Higher FCR was significantly associated with:
- Greater psychological distress ( $r = .75, p < .001$ ).
- Poorer general QoL ( $r = -.81, p < .001$ ).
- Increased physical symptoms ( $r = -.34, p = .003$ ).
- Greater loneliness ( $r = .28, p = .010$ ).
- Lower social support ( $r = -.23, p = .021$ ).
  Multicollinearity among predictors was not problematic (VIF < 5).

Significance and Claims
The authors claim that this study provides the first validation of the FCR-7 specifically for U.S. patients with lung cancer in the immediate post-treatment period. The findings support the FCR-7 as a psychometrically valid, unidimensional screening tool for this population. The study highlights that FCR in lung cancer survivors is not an isolated concern but is strongly intertwined with broader emotional and functional difficulties, including distress, physical symptoms, and social isolation.

The paper asserts that the FCR-7's strong internal consistency and construct validity support its use as a brief screening instrument during early survivorship. By identifying FCR early in the transition from patient to survivor—a period marked by heightened uncertainty—clinicians may facilitate timely interventions to mitigate psychological distress and improve quality of life. The authors note that while the cross-sectional design limits causal inference, the results offer a foundation for future longitudinal research into FCR trajectories and measurement invariance across different survivorship timepoints.