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May 2012, Volume 39, Number 3
Predicting Fear of Breast Cancer Recurrence
and Self-Efficacy in Survivors by Age at Diagnosis
Kim Wagler Ziner, RN, PhD, George W. Sledge Jr., MD, Cynthia J. Bell, RN, PhD,
Shelley Johns, PsyD, ABPP, Kathy D. Miller, MD, and Victoria L. Champion, RN, PhD
Purpose/Objectives: To determine the effect that age at diagnosis has on fear of breast cancer recurrence and to identify the predictors of fear of recurrence using self-efficacy as a mediator.
Design: Cross-sectional survey.
Setting: Two university cancer centers and one cooperative group in the midwestern United States.
Sample: 1,128 long-term survivors.
Methods: Survivors were eligible if they were aged 18–45 years (younger group) or 55–70 years (older group) at cancer diagnosis, had received chemotherapy, and were three to eight years postdiagnosis. Fear of recurrence was compared between younger and older groups. Multiple regression analyses were used to test variables' prediction of fear of recurrence and breast cancer survivor self-efficacy, as well as breast cancer survivor self-efficacy mediation effects.
Main Research Variables: Fear of recurrence, breast cancer survivor self-efficacy, and age at diagnosis.
Findings: Survivors diagnosed at a younger age had significantly higher fear of recurrence, as well as health, role, womanhood, death, and parenting worries. Perceived risk of recurrence, trait anxiety, and breast cancer reminders explained significant variance in fear of recurrence and breast cancer survivor self-efficacy. Breast cancer survivor self-efficacy partially mediated the effects of variables on fear of recurrence.
Conclusions: The findings suggest that breast cancer survivor self-efficacy may have a protective effect for survivors who are younger at diagnosis and have higher perceived risk of recurrence, higher trait anxiety, and more breast cancer reminders. Oncology nurses already use the skills required to support self-efficacy. Additional research is needed to define and test breast cancer survivor self-efficacy interventions.
Implications for Nursing: Oncology nurses are in a key role to assess fear of recurrence and provide self-efficacy interventions to reduce it in breast cancer survivors. Strategies to efficiently address fear of recurrence to reduce psychological distress in survivorship follow-up care are warranted.
The American Cancer Society ([ACS], 2012) estimated that more than 2.6 million women in the United States are breast cancer survivors. With increasing early detection and more effective treatment, breast cancer survival rates continue to rise, making psychosocial consequences of breast cancer, such as fear of recurrence, a concern for many women (Ferrell, Grant, Funk, Otis-Green, & Garcia, 1998a; Northouse, 1981; Vickberg, 2001; Welch-McCaffrey, Hoffman, Leigh, Loescher, & Meyskens, 1989). For most breast cancer survivors, fear of recurrence is a life-long concern (Vickberg, 2001). The prevalence of fear of recurrence suggests that survivors and oncology professionals need research to describe the construct and its prevalence and then test interventions to help survivors manage this problem.
Several factors may be relevant to the study of fear of recurrence. For instance, past work has identified age at diagnosis as an important factor in psychological symptoms of breast cancer survivors (Hewitt, Greenfield, & Stovall, 2006). Other variables such as anxiety, knowledge of symptoms, and breast cancer reminders also have been identified (Vickberg, 2001). In addition, self-efficacy demonstrates promise as a construct related to a woman's ability to handle survivorship problems (Bandura, 1997). Self-efficacy specific to breast cancer survivorship is defined as perceived confidence in managing symptoms and concerns related to diagnosis and treatment of breast cancer. Survivorship literature identifies self-efficacy as a mediator of symptom distress (Cunningham, Lockwood, & Cunningham, 1991; Lev, Paul, & Owen, 1999). The purpose of this research was to determine the effect that age at diagnosis has on fear of recurrence and identify the predictors of fear of recurrence using self-efficacy as a mediator.
Fear of recurrence is a distressing problem for the majority of survivors (Bloom, Stewart, Chang, & Banks, 2004; de Haes, Curran, Aaronson, & Fentiman, 2003; Ferrell et al., 1998a; Härtl et al., 2003; Mast, 1998; Northouse, 1981; Welch-McCaffrey et al., 1989). It interferes with quality of life, enjoyment of life, and global sense of well-being (Cimprich, Ronis, & Martinez-Ramos, 2002; Spencer et al., 1999). In addition, a higher fear of recurrence is correlated with syndromes such as post-traumatic stress disorder in long-term survivors (Mehnert, Berg, Henrich, & Herschbach, 2009; Vickberg, 2003). In one study, fear of recurrence was significantly greater than any other concern, including those related to long-term effects of chemotherapy (Spencer et al., 1999).
Historically, fear of recurrence research has focused only on fear of the cancer returning (Ferrell, Dow, Leigh, Ly, & Gulasekaram, 1995; Härtl et al., 2003; Hilton, 1989; Kornblith et al., 2007; Mast, 1998; Northouse, 1981; Spencer et al., 1999). That approach is limited in that survivors' perceptions about fear of recurrence rarely are unidimensional. For instance, Vickberg (2001) found that one component of fear of recurrence for many women concerned fear about returning to chemotherapy. Some qualitative research has identified additional components of fear of recurrence. For example, survivors report fear of recurrence because they have young children and worry that a recurrence will not allow them to parent as their children grow (Ferrell et al., 1996). As Vickberg (2001, 2003) explored global fear of recurrence and ongoing worries, she found that survivors had concerns about health, womanhood, work, and relationship roles, as well as death. The same view was reported by other researchers (van den Beuken-van Everdingen et al., 2008). Viewing fear of recurrence as a multidimensional construct will allow clinicians and researchers to tailor fear of recurrence interventions.
Age at diagnosis has been identified as an important covariate for fear of recurrence. Kornblith et al. (2007) found that survivors diagnosed at age 55 or younger had a higher fear of recurrence than those diagnosed at age 65 and older, whereas Cimprich et al. (2002) did not find differences in fear of recurrence in those diagnosed when younger than 45, aged 45–65, and older than 65 years. Both studies had fairly small sample sizes. In addition to age at diagnosis, initial treatment may impact fear of recurrence, including type of surgery, use of radiation, and use of tamoxifen or aromatase inhibitors (Vickberg, 2001). Therefore, the current study was designed with distinct age groups and initial treatment was controlled by including those with chemotherapy.
Time since diagnosis is another potential variable related to fear of recurrence. Some studies only assessed survivors one year or less post-treatment (Spencer et al., 1999), whereas others assessed survivors ranging from a few months to a few years post-treatment (Cimprich et al., 2002; Clayton, Mishel, & Belyea, 2006; Connell, Patterson, & Newman, 2006; Härtl et al., 2003; Hilton, 1989; Mast, 1998; Spencer et al., 1999; Vickberg, 2003). Literature describing the relationship between time since diagnosis and fear of recurrence has been hampered by lack of variability in time since diagnosis, an issue that the current study addressed. Women eligible for this study were three to eight years from initial treatment. Therefore, the authors could address the relationship between time since diagnosis and fear of recurrence. Because a commonly accepted survivorship marker is five years postdiagnosis, the authors decided to include a range before and after this marker (e.g., three to eight years) to control for any differences in perception related to length of time since diagnosis.
Several variables that might act as predictors of fear of recurrence were identified in the literature and clinical practice. In this section, the authors will describe those additional variables, including perceived risk of recurrence, knowledge of someone with a recurrence, symptom bother, recurrence signs, trait anxiety, and breast cancer reminders.
Perceived risk of developing cancer has been studied in the context of cancer worry in populations at high risk for cancer (Easterling & Leventhal, 1989; Loescher, 2003). Individuals who had a higher perceived risk of developing cancer reported greater cancer worry and reported more cancer worry in the presence of increased symptoms (Easterling & Leventhal, 1989). In qualitative research, women described knowing someone with a recurrence (including public figures) as a trigger for their own fear of recurrence (Vickberg, 2001).
Little is known about the knowledge survivors have regarding symptoms of recurrence. The presence of breast cancer-related symptoms and non–breast cancer-related symptoms have been found to be associated with thoughts about recurrence (Clayton et al., 2006). Many survivors experience ambiguous symptoms, such as fatigue, and misinterpret these as signs that their cancer has recurred (Lee-Jones, Humphris, Dixon, & Hatcher, 1997). That may lead to behavioral responses such as repeated body checking, persistent requests for tests, and seeking repeated reassurance from healthcare providers during survivorship (Fredette, 1995; Lee-Jones et al., 1997), as well as the tendency to obsess over symptoms (Figueiredo, Fries, & Ingram, 2004; Welch-McCaffrey et al., 1989).
Although trait anxiety has not been found to increase a woman's risk of developing breast cancer (Aro et al., 2005), it has been associated with emotional and physical distress (Ferrell et al., 1998a; Hewitt, Herdman, & Simone, 2004). In women with early-stage breast cancer, trait anxiety has been associated with persistent distress for at least two years postdiagnosis (Bleiker, Pouwer, van der Ploeg, Leer, & Adér, 2000). Knowledge of the role of trait anxiety in fear of recurrence could help healthcare providers as they plan, support, and guide anxiety-reduction interventions.
Long-term survivors report the highest levels of fear of recurrence during healthcare-related visits, such as mammography appointments and visits to the healthcare team. Those routine follow-up appointments may coincide with their anniversary date of diagnosis, the most intense reminder of breast cancer (Spencer et al., 1999; Vickberg, 2003). Breast cancer survivor self-efficacy has been demonstrated to be significantly lower in women diagnosed at age 45 years and younger compared to women diagnosed at 55 years or older (Champion, Sledge, Ziner, Monahan, & Zho, 2010).
Theories of emotion and self-efficacy are the basis of the theoretical framework that guides this study. Emotion theorists posit fear is an emotional response to stimuli perceived as harmful (Lazarus, 1991; Ohman, 2000). Self-efficacy is the confidence to produce desired effects by one's own actions (Bandura, 1997). In this study, self-efficacy is defined as one's confidence in the ability to manage symptoms and emotions related to having breast cancer, including the ability to ask for help, know how and when to report symptoms, and do what is important after breast cancer treatments are completed. Building on the identified antecedent variables and breast cancer survivor self-efficacy, two research questions were proposed: (a) Does fear of recurrence and related subscales differ between survivors diagnosed at younger and older ages, and (b) does breast cancer survivor self-efficacy mediate the relationship between antecedent variables and fear of recurrence?
Design and Sample
This study used a cross-sectional survey design to collect data within a larger breast cancer survivor quality-of-life study. The larger study was designed with a distinct age gap, leaving out women diagnosed from ages 46–54 years, to test differences between women diagnosed with breast cancer at a young age (45 or younger) and women diagnosed at an older age (55–70); this gap was to allow potentially smaller differences to be detected. A theoretical framework proposing relationships among fear of recurrence, as well as research-identified variables, guided data collection and analysis. Surveys were mailed to participants' homes after they provided written informed consent.
A total of 1,128 survivors were included in the study. Survivors were eligible if they had been diagnosed from age 18–45 years for the younger group or age 55–70 years for the older group. Eligibility included chemotherapy as part of their treatment and being three to eight years from initial diagnosis. A total of 744 younger and 937 older eligible survivors were contacted and 505 (68%) younger and 623 (67%) older survivors agreed to participate (see Table 1).
Data Collection
Women were recruited from three settings: two Midwestern university cancer centers and one cooperative oncology group. Recruitment proceeded according to Health Insurance Portability and Accountability Act of 1996 guidelines after Indiana University-Purdue University Indianapolis institutional review board approval. Current healthcare providers asked eligible survivors if they were willing to be approached by the study staff. If survivors agreed, healthcare providers sent survivors' contact information to the study staff, who then contacted interested survivors by phone or in person. Written informed consent was obtained.
Several instruments were used to measure variables hypothesized to affect fear of recurrence. All instruments were tested for content validity by five quality-of-life researchers and three clinical breast cancer experts, with both groups assessing the item-Content Validity Index ([item-CVI] as 1, resulting in an excellent modified kappa statistic [k*] of 1). Twelve survivors confirmed face validity.
Demographic variables, including age at diagnosis, were measured by questions asked as part of the cross-sectional survey. Perceived risk of recurrence was measured by one item: "I will have a breast cancer recurrence at some time in my life," with a five-point Likert-type response scale ranging from 1 (strongly disagree) to 5 (strongly agree). The single item is similar to one previously used to assess perceived risk of developing cancer for those at high risk (Loescher, 2003).
Knowledge of someone with a recurrence included a single dichotomous item asking whether the survivor knew anyone with a breast cancer recurrence. Qualitative research has identified this as a key component of fear of recurrence. The single item was developed for the current study from qualitative literature identifying this concept (Vickberg, 2001).
Knowledge of Recurrence Signs is a scale that was developed based on the American Society of Clinical Oncology's (2001) common clinical symptoms of recurrence. It includes 11 items: six common clinical symptoms of recurrence and five symptoms not associated with recurrence. The six common clinical symptoms of recurrence were (a) bone pain or tenderness lasting more than two weeks; (b) skin rashes, redness, or swelling on breast(s), scar, or chest area; (c) new lumps or other changes in breast(s); (d) chest pain and shortness of breath; (e) persistent abdominal fullness, discomfort, or pain; and (f) changes in weight, particularly weight loss. The five symptoms not associated with recurrence were fever, frequent colds, flu-like symptoms, persistent hot flashes, and changes in sleep patterns. Participants were asked to indicate whether the item was a sign of breast cancer recurrence (i.e., true or false). Correct responses were summed for a total score, with a higher score indicating greater knowledge. Internal consistency reliability (Kuder-Richardson formula 20) was 0.77.
Ridner's Symptom Bother Scale has items to measure the presence and bother of common symptoms associated with arm and chest wall sensations on the mastectomy or lumpectomy side, which were extracted from the Lymphedema Symptom Intensity and Distress Scale–Arm (LSID-A) (Ridner & Dietrich, 2010). A modified version of 12 symptoms, including arm feels heavy, hand swollen, arm swollen, chest swollen, arm feels tight, arm feels hard, numbness, breast pains, skin crawls, change sleeping position because of symptom, and related bother, was used for this study (Cronbach alpha = 0.88). The weighted global index of symptom burden in two studies using the full LSID-A scale had a Cronbach alpha of 0.95 (Ridner & Dietrich, 2010).
The Trait Anxiety Inventory, a 20-item trait subscale, measures how anxious people feel in general (Spielberger, Gorsuch, Lushene, Vagg, & Jacobs, 1983). Median test-retest correlations for the trait anxiety inventory ranged from 0.7–0.77. Concurrent validity with other measures of trait anxiety were high, ranging from 0.73–0.85 (Spielberger et al., 1983). In a pretest, post-test design study of 123 breast cancer survivors, the alpha was reported as 0.92 pretest and 0.94 post-test (Fogarty, Curbow, Wingard, McDonnell, & Somerfield, 1999). In the current sample, Cronbach alpha reliability was 0.93.
Eight items based on survivor accounts of triggers of fear of recurrence (Ferrell et al., 1996; Vickberg, 2001) were provided, including (a) breast cancer fundraising events, (b) helping other women with breast cancer through support groups or individuals calls, (c) my annual date of diagnosis, (d) my mammogram, (e) new symptoms I do not understand, (f) hearing of someone I know who has had a recurrence, (g) routine oncologist appointment, and (h) having blood drawn for tests or IV. An additional choice, "other," allowed survivors to self-identify triggers not on the list. Survivors identified the amount of time in the last month that the reminders caused them to think about breast cancer. The nine-item, Likert-type scale ranged from 1 (not at all) to 5 (all or most of the time), with 0 = not applicable. Responses were summed. For construct validity, Pearson r correlations were used. The Breast Cancer Reminders scale was significantly correlated with the Impact of Events Scale-Revised (IES-r) (r = 0.41, p < 0.001); all IES-r subscales, including avoidance (r = 0.28, p < 0.001), intrusion (r = 0.43, p < 0.001), and hyper-arousal (r = 0.35, p < 0.001); and the fear of recurrence index of the Concerns About Recurrence Scale (CARS) (r = 0.39, p < 0.001) (Ziner, 2008).
The Breast Cancer Survivor Self-Efficacy Scale was developed for the larger study and measured survivors' confidence in dealing with concerns related to breast cancer after treatment. The scale used a 14-item, five-point Likert-type scale with responses ranging from 1 (strongly disagree) to 5 (strongly agree). Items included issues such as being able to ask for help when problems arise, dealing with physical symptoms, and emotional issues from having breast cancer. Responses were summed for a total score. Construct validity was supported with a confirmatory structural equation model (Champion et al., 2011). Cronbach alpha reliability was 0.93 in this sample.
Fear of recurrence was measured using CARS (Vickberg, 2003). CARS is a two-part instrument developed for survivors assessing overall fear of recurrence (fear of recurrence index) and worries related to recurrence. Subscales include death worries (2 items), health worries (11 items), role worries (6 items), and womanhood worries (7 items). A fifth subscale, parenting worries (2 items), was added on the advice of younger survivors who reviewed the measures prior to the current study and was approved by Vickberg (personal communication, July 6, 2004). All subscales employed a five-point Likert-type response format ranging from 0 (not at all) to 4 (all or most of the time) (Vickberg, 2003). The internal consistency reliability of the subscales ranged from 0.81–0.93.
Data Analysis
SPSS®, version 14, was used for all analyses. Independent sample t tests were used to compare differences in fear of recurrence among younger and older survivors. Multiple linear regression analyses were used to test the association between each variable and fear of recurrence while adjusting for the effects of other variables. The full sample of 1,128 was available for the independent t test; however, because the authors chose not to impute missing data, the SPSS program included a reduced sample of 1,076 within the multiple regression analysis.
A total of 1,128 survivors were included in the analysis, with about 45% being diagnosed at 45 or younger and 55% being diagnosed from age 55–70. A majority was Caucasian (92%), married (75%), had at least some college education (64%), and had a household income of $50,000 or more (62%). All women were treated with chemotherapy and had some type of surgery; 47% had a lumpectomy, 51% had a mastectomy, and about 2% had both.
Research Question 1 tested for differences between the younger and older survivors on the CARS fear of recurrence index and subscales. Overall, younger women experienced more fear and worry than older women. All t values for independent tests were significant and ranged from 7.7–15.4 (see Table 2). Women diagnosed at a younger age had a significantly higher mean fear of recurrence index and higher mean worries for health, role, womanhood, death, and parenting compared to women diagnosed at an older age. The greatest difference was seen with the parenting worries subscale.
Research Question 2 sought to determine the mediation effect of breast cancer survivor self-efficacy on antecedent variables in predicting fear of recurrence. Multiple linear regressions were used to test the relationships of the antecedent variables, breast cancer survivor self-efficacy, and fear of recurrence using the Baron and Kenny (1986) method. If the unstandardized regression coefficients changed once breast cancer survivor self-efficacy was added to the analysis, the methods suggested by Frazier, Tix, and Barron (2004) were used to test for significance of the mediation.
The antecedents first were regressed on fear of recurrence. Variables negatively associated with fear of recurrence included age at diagnosis (p = 0.001), perceived risk of recurrence (p = 0.001), trait anxiety (p = 0.001), and breast cancer reminders (p = 0.001). Antecedents explained 38% of the variance in fear of recurrence (see Table 3). Other predictors were not significant.
As a second step, breast cancer survivor self-efficacy was regressed on the antecedents. While controlling for other predictors in the model, age at diagnosis was nonsignificantly related to breast cancer survivor self-efficacy. Higher perceived risk of recurrence (p = 0.07), knowledge of someone with a recurrence (p = 0.004), symptom bother (p < 0.001), trait anxiety (p < 0.001), and breast cancer reminders (p = 0.014) all were related inversely to breast cancer survivor self-efficacy.
As a third step, fear of recurrence was regressed on the mediating variable breast cancer survivor self-efficacy (see Table 4). Breast cancer survivor self-efficacy explained about 18% (p < 0.001) of the variance in fear of recurrence. Higher breast cancer survivor self-efficacy predicted lower fear of recurrence.
Finally, fear of recurrence was regressed on antecedent variables and breast cancer survivor self-efficacy. Mediation is indicated when the strength of the relationship between the antecedents and outcome variable is reduced when the mediator enters the analysis (Baron & Kenny, 1986). Therefore, fear of recurrence was regressed on antecedents plus breast cancer survivor self-efficacy (see Table 5). About 18% variance was accounted for by antecedents and self-efficacy on fear of recurrence (p = 0.001).
The strength of the relationship among antecedents and fear of recurrence changed significantly when breast cancer survivor self-efficacy was added to the analysis. For each coefficient, a decrease in the regression coefficient once breast cancer survivor self-efficacy was added to the analysis was tested for significance of change (Frazier et al., 2004). The coefficient change was significant (p = 0.05) for age at diagnosis, perceived risk of recurrence, trait anxiety, and breast cancer reminders. Specifically, the standardized regression coefficients became smaller (less strength) for age at diagnosis (–1.9 to –1.8), perceived risk of recurrence (2.46–2.34), trait anxiety (0.13–0.077), and breast cancer reminders (0.215–0.205). Breast cancer survivor self-efficacy is a significant partial mediator of the relationships between fear of recurrence and age at diagnosis, perceived risk of recurrence, trait anxiety, and breast cancer reminders. Breast cancer survivor self-efficacy was significantly related to fear of recurrence with a regression coefficient of –0.183 (p < 0.001), which explained about 3% of the unique variance in fear of recurrence. Higher breast cancer survivor self-efficacy predicted lower fear of recurrence.
The authors first sought to determine whether a difference existed between breast cancer survivors who were diagnosed at age 45 years or younger compared to those diagnosed at 55–70 years in relation to fear of recurrence. While controlling for time since diagnosis and treatment, survivors diagnosed in the younger age group had higher fear of recurrence and related worries than survivors in the older age group, which is consistent with previous research that reported younger age was associated with more troublesome thoughts of recurrence indirectly through the relationship between higher symptom bother and younger age (Clayton et al., 2006). Other researchers have described a relationship between younger age at diagnosis and higher fear of recurrence (Härtl et al., 2003; Hilton, 1989; Mast, 1998; Vickberg, 2003).
The findings suggest women diagnosed at a younger age may be at higher risk for fear of recurrence in general and of specific worries about fear of recurrence. Age group at diagnosis was considered an antecedent variable in the current study and younger age at diagnosis predicted higher fear of recurrence, but not breast cancer survivor self-efficacy. Other antecedent variables, including perceived risk of recurrence, trait anxiety, and breast cancer reminders, predicted fear of recurrence and breast cancer survivor self-efficacy. The relationship of those antecedent variables with fear of recurrence was mediated by breast cancer survivor self-efficacy. Of those variables, anxiety and thoughts of breast cancer have been explored by others. A study by Mehnert et al. (2009) found that anxiety was related to moderate to high levels of fear of recurrence. After breast cancer is diagnosed, anxiety often has been considered a part of psychosocial distress, a quality-of-life domain that includes fear of recurrence (Ferrell et al., 1998a; Hewitt et al., 2004).
Women with more thoughts about breast cancer triggered by breast cancer reminders had higher fear of recurrence. That finding was supported by qualitative results in the literature (Ferrell et al., 1998b; Vickberg, 2001) and research with older survivors (Clayton et al., 2006). Events that trigger fear of recurrence often were associated with healthcare-related activities such as mammograms, clinic visits, and blood work. Being cognizant of those triggers is an important consideration for survivors and healthcare providers.
Three antecedents did not impact fear of recurrence: knowing someone with a recurrence, knowledge of recurrence signs, and symptom bother. However, other qualitative reports by survivors described knowing someone with a recurrence as a trigger for their own fear of recurrence (Vickberg, 2001). Although the current study's findings indicated that most survivors had a fairly accurate knowledge of recurrence signs, this knowledge was not correlated with fear of recurrence; higher survivors' knowledge of recurrence signs alone did not seem to reduce fear of recurrence. Finally, symptom bother was not related to fear of recurrence, although the presence of breast cancer-related symptoms and non–breast cancer-related symptoms have been associated with thoughts of recurrence (Clayton et al., 2006). The difference in the current study may have to do with the type of symptoms reported. In this study, symptoms were not related to clinical signs of breast cancer, but instead were clinical signs related to breast cancer treatment complications (e.g., numbness, discomfort).
Survivors with higher breast cancer survivor self-efficacy had lower fear of recurrence. In addition, breast cancer survivor self-efficacy mediated the relationship between younger age at diagnosis, higher perceived risk of recurrence, higher trait anxiety, more breast cancer reminders, and higher fear of recurrence, indicating that breast cancer survivor self-efficacy may have a protective effect. Self-efficacy for coping with cancer (Merluzzi, Nairn, Hegde, Martinez Sanchez, & Dunn, 2001) found that patients with higher cancer self-efficacy during treatment and immediately after experienced higher general quality of life, less anxiety, and a greater sense of well-being.
Although having clearly delineated age at diagnosis groups was beneficial for the comparison of fear of recurrence in younger and older survivors, conclusions cannot be drawn about fear of recurrence in survivors diagnosed from ages 46–54, as these women were not included in the study. The sample primarily included women who were Caucasian and English speaking, so the results may not generalize to non-Caucasian or non-English speaking survivors. Moreover, the study was a cross-sectional survey, which does not allow any conclusions about fear of recurrence over time.
Implications for Nursing
The study's findings indicate that breast cancer survivor self-efficacy may be an important construct to use in interventions addressing fear of recurrence in breast cancer survivors. Providing breast cancer survivors with the knowledge and skills to deal with the symptoms resulting from breast cancer may help decrease fear of recurrence as well as anxiety and perceived risk of recurrence.
Oncology and family practice nurses can support survivors by validating that fear of recurrence is an ongoing concern for the majority of survivors and that survivors diagnosed at a younger age are at a higher risk for fear of recurrence and worries about health, life roles, womanhood issues, and parenting. Nurses can educate survivors to anticipate common fear of recurrence triggers. For example, the current study's findings and qualitative reports discuss healthcare provider visits as triggers for higher fear of recurrence. Nurses can tell survivors that experiencing fearful responses to upcoming healthcare provider visits is normal and can collaborate with survivors to develop a plan to reduce any quality-of-life interference these understandable fears might cause.
Oncology nurses already possess and use the skills required to build and sustain self-efficacy. According to Bandura (1997), self-efficacy is accomplished through mastery, vicarious experiences, verbal persuasion, and emotional arousal. Nurses coach their patients with information and skill-building to achieve mastery. Nurses also use verbal persuasion (e.g., "You can do this!") to help patients manage symptoms and emotions. In addition, nurses provide knowledge of what is normal among patients' experiences and refer to trusted support networks that provide vicarious experiences. Emotional arousal may be linked to the ability to act; therefore, nurses assess their patients for emotions that can help motivate them to take needed action or for higher emotional responses that may cause patients to avoid actions and thereby identify those patients who need a referral for more extensive intervention. Therefore, once research provides the information on how survivors build breast cancer survivor self-efficacy, nurses will be prepared immediately to translate this information to practice.
Although the results of this research provide possibilities for intervention, additional research is needed. First, interventions must be defined and tested to develop and strengthen breast cancer survivor self-efficacy. Second, researchers must establish how survivors determine their risk of recurrence and how perceived risk of recurrence relates to actual risk of recurrence (e.g., stage at diagnosis), thus identifying interventions to normalize survivors' perceived risk of recurrence. Finally, breast cancer survivor self-efficacy reduced the effect of younger age at diagnosis on fear of recurrence, so understanding which other variables or combinations of variables share variance with age at diagnosis warrants additional exploration. Identifying one or more variables that influence that relationship could add to how fear of recurrence is managed, particularly in women diagnosed at younger ages.
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Figueiredo, M., Fries, E., & Ingram, K.M. (2004). The role of disclosure patterns and unsupportive social interactions in the well-being of breast cancer patients. Psycho-Oncology, 13, 96–105.
Fogarty, L.A., Curbow, B.A., Wingard, J.R., McDonnell, K., & Somerfield, M.R. (1999). Can 40 seconds of compassion reduce patient anxiety? Journal of Clinical Oncology, 17, 371–379.
Frazier, P.A., Tix, A.P., & Barron, K.E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51, 115–134. http://dx.doi.org/10.1037/0022-022.214.171.124
Fredette, S.L. (1995). Breast cancer survivors: Concerns and coping. Cancer Nursing, 18, 35–46.
Härtl, K., Janni, W., Kästner, R., Sommer, H., Strobl, B., Rack, B., & Stauber, M. (2003). Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients. Annals of Oncology, 14, 1064–1071. http://dx.doi.org/10.1093/annonc/mdg289
Hewitt, M., Greenfield, S., & Stovall, E. (2006). From cancer patient to cancer survivor: Lost in transition. Washington, DC: National Academies Press.
Hewitt, M., Herdman, R., & Simone, J. (2004). Meeting psychosocial needs of women with breast cancer. Washington, DC: National Academies Press.
Hilton, B.A. (1989). The relationship of uncertainty, control, commitment, and threat of recurrence to coping strategies used by women diagnosed with breast cancer. Journal of Behavioral Medicine, 12(1), 39–54. http://dx.doi.org/10.1007/BF00844748
Kornblith, A.B., Powell, M., Regan, M.M., Bennett, S., Krasner, C., Moy, B., . . . Winer, E. (2007). Long-term psychosocial adjustment of older vs younger survivors of breast and endometrial cancer. Psycho-Oncology, 16, 895–903. http://dx.doi.org/10.1002/pon.1146
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Vickberg, S.M. (2003). The Concerns About Recurrence Scale (CARS): A systematic measure of women's fears about the possibility of breast cancer recurrence. Annals of Behavioral Medicine, 25(1), 16–24.
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Kim Wagler Ziner, RN, PhD, is an assistant researcher in the School of Nursing and George W. Sledge Jr., MD, is a distinguished professor in the School of Medicine, both at Indiana University in Indianapolis; Cynthia J. Bell, RN, PhD, is a postdoctoral fellow in the School of Nursing at Vanderbilt University in Nashville, TN; Shelley Johns, PsyD, ABPP, is a postdoctoral fellow at the Walther Cancer Foundation in Indianapolis, IN; and Kathy D. Miller, MD, is an associate professor in the School of Medicine and Victoria L. Champion, RN, PhD, is a distinguished professor in the School of Nursing, both at Indiana University. This research was supported by the American Cancer Society Scholarship in Cancer Nursing (DSCN-05-182-01) and grant #RSGPB-04-089-01-PBP (principle investigator: Champion); an Indiana University Mary Margaret Walther Pre-Doctoral Fellowship; and a National Cancer Institute training grant (R25 CA 117865-01A11) (principle investigator: Champion). This study was conducted by the Eastern Cooperative Oncology Group (Robert L. Comis, MD) and supported, in part, by Public Health Service grants (CA21115 and CA37604) and from the National Cancer Institute Division of Cancer Prevention, National Institutes of Health, and the Department of Health and Human Services. Its contents are solely the responsibility of the authors and do not represent the official views of the National Cancer Institute. Ziner can be reached at firstname.lastname@example.com, with copy to editor at firstname.lastname@example.com. (Submitted February 2010. Accepted for publication June 20, 2011.)


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The khichdi with lots of flavors and texture will surely make everyone crave for more. It is a wholesome nutritious meal in itself, which is an added benefit. A traditional Punjabi Dessert. Long grained, highly aromatic Basmati rice and sugar syrup are the key ingredients of this dish. A saffron colored dish, it is usually served flavored with cardamoms, cloves, cinnamon and kesar. I remember this as one of the most loved dishes of our household when I was a child. Crisp Indian bread baked in a tandoor oven , Amritsari kulcha is a must-have dish from Punjab. It goes well with spicy Punjabi chhole, curd or all by itself.
Top it with a dollop of butter for a melt-in-the-mouth dish. The quintessential Punjabi dish is an unmistakable part of most celebrations. The spicy curry made with kidney beans, tomatoes and onions, mixed with boiled rice can be garnished with coriander for an added punch of taste.
Sabyasachi Satpathy on Instagram: "Happy Guruparv 🙏 Bhagwan hum sabko Saddbudhi pradaan kare ❤🙏"
This baked savory dumpling is filled with a spicy stuffing of potato, lentils, onions, peas and cottage cheese. It is usually conical in shape with a crisp maida shell and piping hot stuffing.
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It is served with a tangy chutney that further enhances its heavenly flavor. We bet you can't guess the price of Nita Ambani's diamond encrusted bag! Rohit Sharma's pretty wife Ritika Sajdeh is a style diva you can't miss! Here's everything you need to know about babies and skin rashes. How much weight should you really gain during pregnancy. These are the top 5 mistakes ALL new parents make! Babies born to overweight women are 3.
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About Guru Nanak Jayanti
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Gurpurab 2018- The Significance of The Celebration of Guru Nanak's Birth
Together they organised gatherings for Hindus and Muslims where they sang hymns to praise the creator. Guru Nanak was married at the age of 18 and bore two sons. But when Guru Nanak turned 28, he disappeared for three days. Upon returning, he said that there is no Hindu or Muslim but only one formless God which could be worshipped by all.
Guru Nanak said that a constant remembrance of God, called naamsimran , is the only way to liberation. These teachings of Guru Nanak stood out against the religious practices of his time and became part of Guru Granth Sahib, the holy book of the Sikhs. Like us on Facebook or follow us on Twitter and Instagram for latest news and live news updates. Budget : Find the latest news on ndtv.

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Custom URL error without www
Good evening, I have a problem with a custom URL.
If I type www.giovannibertagna.com I regularly access smugMug but if I use giovannibertagna.com it gives me an error.
I tried to follow the guide, but I can't solve it. I purchased the domain through Smugdomains.
Follow me on Diario Fotografico (Photo Diary) and Blog
Hikin' Mike Walkin' like a Penguin! Atwater, CaPosts: 4,553Registered Users Major grins
Best to contact the help desk and not the forum.- Mike
Images in the Backcountry
My SmugMug Customizations | Adding CSS to Your Site | SEO for the Photographer | SmugMug Help Desk0
Allen "tweak 'til it squeaks" St. Louis, MoPosts: 9,725Registered Users Major grins
One part of the domain is not fill out correctly. Been ages since been through this. Many post on Dgrin.
See if this helps.
This is the important part.
"If you are setting up a domain you need to use a CNAME and A record:"
www CNAME pointing to domains.smugmug.com
@ A record pointing to 220.127.116.11
Not sure if the numbers still good.Al - Just a volunteer here having fun
My Website | My Blog0
Thanks, I write to support.
@Allen I had already entered the parameters that you indicated, but nothing :-(
Follow me on Diario Fotografico (Photo Diary) and Blog0
rainforest1155 SmugMug Support Hero Posts: 4,508Registered Users Major grins
It's been a long time since we supported that type of A record set up. Please don't use the A record IP address that Allen mentioned. For a domain to work without the www in front, you would set up a regular redirect / forward for your root domain (example.com) at your domain host to:
without any masking or framing.
If you're unsure on how to do that, your domain host should be able to assist you further with this.Sebastian
SmugMug Support Hero0


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Check-in: From 14:00
Check-out: Before 12:00
Komodo Resort & Diving Club is located in area / city Komodo.
There are plenty of tourist attractions nearby, such as Kanawa Island within 4.84 km, and Kelor Island within 16.86 km.
About Komodo Resort & Diving Club
Be ready to get the unforgettable stay experience by its exclusive service, completed by a full range of facilities to cater all your needs.
Enjoy luxurious treats and incomparable experience by staying at Komodo Resort & Diving Club.


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Topic : Resume template for college student internships.
Author : Glorianna Massey.
Published : Mon, Aug 26th 2019 16:12 PM.
Format : jpg/jpeg.
First of all, you should be able to recognize the essentials of a good invoice template sample. Certain features are common to most small business receipt template. For instance, it has to have the name of the company and its address, as well as the contact information of the customer. It necessarily describes the kind of services offered and the price agreed for providing them. Usually, companies include their logo in the customer invoice template and, depending on the nature of business, they may mention the payment terms and the breakdown of goods or services offered.
You can easily create an invoice paid template containing all the essential features by making use of the word invoice template offered without charge on the Internet. You can get various types of invoice template design. You may have an billing invoice template word for providing any specific service or goods or just labor. You also can find business form template for pro-forma invoices.
While writing can be easy for some, it can be a very difficult endeavor for others. I do not know how many times I have watched students and adults fret endlessly over a writing assignment. Here are a few rules for making it easier for those of you having a difficult time with writing assignments. The introduction, in journalistic terms, the lead, should bring the reader in , so to speak. If you are writing a freelance article and want to collect a check for your work, this has to be strong. The person in whom you are setting the hook is the editor or the publisher. You have to pique their interest strongly enough to entice them to read all the way to the end of the article. If you are successful, they may offer you the assignment or pay you for the piece.


text: I have aquired a 1994 Honda Civic (European) and had a few questions. Main questions, what would I need to make it US spec so I can ship it home. and where can I get these parts? Next question is, What are some good performance parts for the car for street racing? Any opnions would be great. thank you.


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We are making gun sales great again! Our first priority is to provide the best customer service in the business! Our success is based on a relationship with our customer. Even online we want you to feel like you know us and trust us with all your 2A needs.
Mfg Item #: 708CS
Federal PowerShok, 7MM-08, 150 Grain, Sierra, 20 Round Box 708CS


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Sven-Goran Eriksson yesterday again pledged his future to England after being linked with the potential managerial vacancy at Real Madrid.
Eriksson was linked with Real Madrid almost immediately after coach Jose Antonio Camacho had resigned only a few weeks into the new season.
However, the Swede categorically stated only last month that he would not resign his current post unless England failed to qualify for the 2006 World Cup finals. And he was yesterday just as insistent that he would honour his contract, which was extended only a few months ago until 2008.
Speaking at a Uefa national coaches forum in Stockholm, he responded to reports that intermediaries from Real had already started to informally sound out his availability.
Eriksson declared: "I do not know anything about it. I have not talked to anyone from Real Madrid. I have a contract and that's it.
"I think that Real Madrid already have a new coach don't they? So it's not even a matter to discuss. I haven't had any approaches from anyone and that's it."
His agent, Athole Still, added: "Neither Sven nor myself has had any contact whatsoever with Real Madrid in the past two days."
Although former assistant coach Mariano Garcia Remon has been appointed as Camacho's replacement, a lack of immediate success could see him become merely a stop-gap move, with Eriksson having previously been courted by Real president Florentino Perez. Moving to Spain could also enable him to escape the current spotlight on his private life in this country, while allowing him to coach David Beckham, Michael Owen and ex-Newcastle defender Jonathan Woodgate at club level.
There are, meanwhile, some figures on the Football Association's board who might actually welcome Eriksson's departure, especially if Real were to pay the FA up to #4m compensation.
Despite previously maintaining his commitment to England, that did not stop the Swede talking to Chelsea chief executive Peter Kenyon last season. And he was also linked with Manchester United before Sir Alex Ferguson's U-turn on staying.
England skipper Beckham might relish the possibility of Eriksson arriving in Madrid.
But he insisted: "Sven is a great manager and in the last couple of years he's been linked with many jobs.
"That will always happen, clearly there will be speculation. But he's England manager and, as far as I know, he will carry on being England manager."


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Events for 25 August, 2019
Events Search and Views Navigation
11:00 am
Yoga in Trillium Park
Join us for free Yoga in Trillium Park every Saturday and Sunday mornings along with monthly sunset sessions at Trillium Park. Classes will be led by Alexandria Santaguida of NULOVE. All levels are welcome. For more information and to receive class reminders, please contact us at: email@example.com. Please bring your own mat. See below for […]Find out more »
3:00 pm
Jazz Sundays at the Vista featuring The Ben Frost Trio
New this year, the Vista Eatery has turned into a weekly live music venue for emerging jazz musicians from across Ontario to perform on our waterfront patio! These musicians are students or recent grads from University of Toronto, York University, Humber College and Mohawk College. So sit back in a muskoka chair and let us […]Find out more »
4:30 pm
7:00 pm
Paint in the Park – Night Out Edition
We've teamed up with Art Tonite, so you can stoke your creative spark into a burning flame that's hotter than the summer heat! Families are welcome to get in touch with their inner artists every Saturday and Sunday afternoons during our Paint in the Park events, located at the Vista Eatery on the waterfront. We provide […]Find out more »


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- Mac
- Developer Tools
- Webmaster Tools
The suite contains tools and algorithms for establishing and maintaining a development environment. It creates regular software, web applications, etc. The app serves as a multi-PHP server and does not require stopping and restarting when shifting between projects.
Our website provides a free download of MAMP PRO 5.3 for Mac. The program lies within Developer Tools, more precisely Webmaster Tools. This application was developed to work on Mac OS X 10.6.6 or later. The unique identifier for this application's bundle is de.appsolute.mamppro.
The most popular versions of the application are 3.0, 2.2 and 2.1. The most frequent installer filenames for the application include: mamp_mamp_pro_3.0.3.pkg, mamp_mamp_pro_3.0.5.pkg, mamp_mamp_pro_3.0.6.pkg, mamp_mamp_pro_18.104.22.168.pkg and mamp_mamp_pro_2.2.zip etc. The actual developer of this software for Mac is appsolute GmbH.
From the developer:
MAMP PRO is the commercial, professional grade version of the classic local server environment for OS X: MAMP.
You may want to check out more Mac applications, such as Sequel Pro, RiffMaster Pro or PDF Reader Pro Free, which might be related to MAMP PRO.
Please add a comment explaining the reasoning behind your vote.
MAMP PRO is a very good server for working with PHP. My admin and I recommend it.
Network Tools
System Optimization
System Optimization
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Collectives In: Operations Management
Michael KruseDirector Creative Services
Experienced Creative Services & Creative Operations Director for in-house agencies that have included Underwriter's Laboratories, Sotheby's Auction House and Condé Nast.
Brian AdamovichPartner, Marketing and Operations Leader
A Marketing Operations & Business Strategist whose areas include marketing strategy & execution, project management, and growth initiatives. Clients include Salesforce, Singer, and True Religion.
Farzana NasserDigital Marketing Executive & Strategist
A strategic marketing executive & tech entrepreneur who excels at growing brands & structuring marketing organizations to scale. Clients are Cheerios, Betty Crocker, AccuWeather, Vera Bradley, and Unilever.
Gaby GondaExecutive Recruiter
As an Executive Recruiter, Gaby is focused on marketing, technology, data science, and sales roles for clients.
Doug NugentCustomer Success & Retention Expert
A Customer Experience & CRM expert who optimizes customer journeys for loyalty & operational efficiency. He brings strategies to fruition with companies like Envoy, AccuWeather, Walmart and P&G.