Diagnosis with cancer, the possible long- and short-term side effects of treatment produce significant changes in the lives of patients, as well as of their proximal and distal environments (families, friends, co-workers, etc.) (Singer, 2018), significantly affecting the quality of the patients’ physical, personal, professional, social, spiritual lives (Holland et al., 2010; Grassi and Riba, 2012). Approximately one-third of the cancer patients treated in acute-care experience intense symptoms of anxiety, depression, traumatic reactions, etc. (Mehnert et al., 2013; Nakash et al., 2014). Additionally to these psychological reactions, quite frequently, patients experience increases in existential worries/fears regarding the possible recurrence or progression of the disease, which further impacts the quality of their lives (QoL) (Fiszer et al., 2014; Curran et al., 2020). The relevant literature in psycho-oncology indicates that regardless the type of cancer and method of assessment, 24–97% of cancer survivors experience varying degrees of fear of cancer progression/recurrence (Mehnert et al., 2013; Simard et al., 2013), usually defined as “fear, worry, or concern about cancer returning or progressing” (Lebel et al., 2013) (p. 3).

According to the theoretical framework of the psycho-oncology literature fear of cancer recurrence/progression (FoP) is to some degree, a normal and adequate reaction to the threats and uncertainties survivors may experience at any stage of the illness- and survivorship-trajectory (Koch et al., 2013; Simonelli et al., 2017). Research indicates that FoP may persist years after the remission of the disease and cessation of treatment (Wagner et al., 2011). However, FoP may, in some cases attain maladaptive dimensions, leading to dysfunctional behavioral, cognitive, and emotional responses (Gotze et al., 2019). If these, otherwise realistic fears, become long-lasting and exaggerated, they may additionally contribute to the deterioration of the cancer survivors’ QoL (Herschbach and Dinkel, 2014). Since worldwide FoP is one of the most frequently cited unmet needs reported by the majority of cancer survivors (Crist and Grunfeld, 2013), research has intensified in this area to identify the most important risk and protective factors of this psychological phenomenon (for more, see Shay et al., 2016; Simonelli et al., 2017). Psycho-oncological research indicates that QoL is significantly associated with survivorship rates (Vodermaier et al., 2017; van Amelsfoort et al., 2022). Consequently, one of the most important factors in the ebb and flow of the FoP in the illness-trajectory is the certainty of access to treatment and the periodic follow-up examinations (Koral and Cirak, 2021).

The COVID-19 pandemic significantly changed the conditions and quality of human life worldwide, representing a significant source of distress, anxiety, uncertainty, loneliness, and confusion to the general population (Peteet, 2020). Obviously, this epidemic had a much deeper effect on cancer patients and survivors (Brivio et al., 2020). Besides the usual distress accompanying the entire oncological experience, cancer survivors had to additionally confront with the increased risk of contamination due to suppressed immune functioning (Gheorghe et al., 2021), and the restricted access to treatment and periodic follow-ups, which in many cases significantly increased the FoP (de Azambuja et al., 2020).

Economically, Romania is considered to belong among the developing countries LMIC (Low-Middle Income Countries) (WorldBank, 2022), with the second lowest share of GDP/capita dedicated to healthcare in the European Union (European Commission, 2021). Furthermore, Romania is characterized by a not very well-supported development of psychosocial oncology care where funding is frequently donor-dependent (Grassi et al., 2016). Consequently, it is not farfetched to expect that the situation of Romanian cancer patients and survivors during the COVID-19 pandemic has become even more dramatic, than in non-pandemic periods of life.

Empirical literature indicates that those cancer patients/survivors who experience higher levels of FoP indicate significantly lower levels of personal, professional, social, etc. QoL, impaired cognitive functioning (e.g., difficulties making plans for future due to the increased levels of uncertainty), hypochondria, excessive use of healthcare services, development of anxiety and depressive disorders, etc. which further on may affect their physical functioning as well (Hart et al., 2008; Lebel et al., 2013; Cincidda et al., 2022a,b). The increasingly high survival rates and life expectancy reclaim the thorough inquiry of the relationship between these two constructs (Shin et al., 2017).

The CANPRIM project is the first nationwide study to address psychosocial burden, distress, and pathways among outpatient cancer patients in primary care in Romania. This questionnaire-based survey used an exploratory, descriptive, and cross-sectional approach.

Depending on tumor location, a heterogeneous, mixed sample of outpatient oncology patients was studied, comprising a nationwide sample of 330 individuals registered with public and private primary care providers in 34 of 41 counties, without restriction by cancer type (solid or hematologic) or stage. To be eligible for the study, outpatient participants had to be at least 18 years of age, provide informed consent, be mentally and physically capable of completing the questionnaire, and have functional digital literacy to perform the computerized measurement. Data collection was conducted via the CANPRIM application and by completing a paper-pencil questionnaire per participant’s choice in an anonymous and confidential process with coded responses. We had to use multiple strategic approaches (i.e., collaboration with primary care providers, collaboration with state and private medical oncology institutions, collaboration with psycho-oncologists and NGOs, and digital assessment tool) to collect data because our research was conducted in the context of the COVID-19 pandemic during a consecutive 8-months period in 2021. This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Institutional Review Board (IRB) approval 16.260/30.10.2020 by the Scientific Council of Babeș-Bolyai University of Cluj-Napoca, Romania. Therefore, this study met all medical and research ethics requirements.

In order to investigate our research questions, we conducted a correlation and hierarchical regression analysis. Table 1 presents descriptive statistics of the assessed variables, with the 3 categories of FoP (low, medium, and high), obtained after calculating the mean +/− one Standard deviation. Our results indicate that below 20% of the cancer patients/survivors indicate low, and over 11% (11.30–16.33%) high levels of FoP.

Next, in order to investigate possible differences in the assessed variables depending on low-medium-high levels of FoP, we performed Multivariate General Linear models (MGL), and applied post hoc Hochberg GT2 (significant differences are presented in Table 2).

Our results indicate that small to medium size effects were produced in the following cases: low-medium-high levels of fear regarding family/partnership problems produced significant differences in the quality of physical [F(_2,283) = 8.26, p = 0.000, partial η² = 0.056], role [F(_2,283) = 6.03, p = 0.003, partial η² = 0.041], cognitive [F_(2,283) = 4.21, p = 0.016, partial η² = 0.029], social [F(_2,283) = 9.77, p = 0.000, partial η² = 0.066], and financial [F(_2,283) = 6.10, p = 0.003, partial η² = 0.042] functioning; low-medium-high levels of occupation-related fears produced significant differences in the quality of physical [F(_2,283) = 3.87, p = 0.022, partial η² = 0.027], role [F(_2,283) = 5.86, p = 0.003, partial η² = 0.040], emotional [F(_2,283) = 8.95, p = 0.000, partial η² = 0.059], cognitive [F(_2,283) = 6.58, p = 0.002, partial η² = 0.044], and social [F(_2,283) = 7.43, p = 0.001, partial η² = 0.050] functioning, while low-medium-high levels of FoP_coping (successful dealing with anxiety/fears/worries) produced significant differences only in the quality of emotional functioning [F(_2,283) = 4.35, p = 0.014, partial η² = 0.030].

Medium to large effect sizes were produced by: low-medium-high levels of anxiety related to the disease (FoP_affective reactions) produced significant differences in the quality of physical [F(_2,283) = 24.41, p = 0.000, partial η² = 0.15], role p[F(_2,283) = 15.06, p = 0.000, partial η² = 0.098], emotional [F(_2,283) = 45.74, p = 0.000, partial η² = 0.249], cognitive [F(_2,283) = 16.55, p = 0.000, partial η² = 0.107], social [F(_2,283) = 15.03, p = 0.000, partial η² = 0.099], and financial [F(_2,283) = 14.85, p = 0.000, partial η² = 0.098] functioning; low-medium-high levels of fear regarding the way the illness may affect the relationship with the partner produced significant differences in the emotional [F(_2,283) = 10.80, p = 0.000, partial η² = 0.072], and social [F(_2,283) = 9.77, p = 0.000, partial η² = 0.066] dimensions of the QoL. Different levels in fear related to occupational changes produces by the illness produce significant differences in the emotional [F(_2,283) = 8.95, p = 0.000, partial η² = 0.059], and financial [F(_2,283) = 15.02, p = 0.000, partial η² = 0.097] dimensions of the quality pf life. Finally, low-medium-high levels of fear related to loss of independence produce significant differences in the following dimensions of the QoL: physical [F(_2,283) = 15.76, p = 0.000, partial η² = 0.095], role [F(_2,283) = 15.39, p = 0.000, partial η² = 0.093], emotional [F(_2,283) = 33.19, p = 0.000, partial η² = 0.182], cognitive [F(_2,283) = 13.87, p = 0.000, partial η² = 0.085], social [F(_2,283) = 18.33, p = 0.000, partial η² = 0.110], and financial [F(_2,283) = 20.47, p = 0.000, partial η² = 0.122].

Next, in order to identify the association patterns between variables, we conducted zero-order correlation analyses. Results are presented in Table 3. Our results indicate that the affective component of FOPQ is significantly correlated with all components of subjective well-being (physical_functioning: r = −0.43, p < 0.01; role_functioning: r = −0.32, p < 0.01; emotional_functioning: r = −0.56, p < 0.01; cognitive_functioning: r = −0.33, p < 0.01; social_functioning: r = −0.27, p < 0.01; financial difficulties: r = 0.31, p < 0.01). Partnership/Family is also significantly associated with physical_functioning: r = −0.16, p < 0.01; role_functioning: r = −0.20, p < 0.01; emotional_functioning: r = −0.30, p < 0.01; cognitive_functioning: r = −0.18, p < 0.01; social_functioning: r = −0.21, p < 0.01; and financial difficulties: r = 0.22, p < 0.01. Similar association patterns may be observed in the case of: occupation (physical_functioning: r = −0.18, p < 0.01; role_functioning: r = −0.20, p < 0.01; emotional_functioning: r = −0.28, p < 0.01; cognitive_functioning: r = −0.18, p < 0.01; social_functioning: r = −0.21, p < 0.01; financial difficulties: r = 0.27, p < 0.01), loss of independence (physical_functioning: r = −0.41, p < 0.01; role_functioning: r = −0.37, p < 0.01; emotional_functioning: r = −0.52, p < 0.01; cognitive_functioning: r = −0.31, p < 0.01; social_functioning: r = −0.34, p < 0.01; and financial difficulties: r = 0.77, p < 0.01); however, the coping component of FoP presents a weak, significant correlation only with financial difficulties (r = 0.13, p < 0.05).

Based on the association patterns presented in Table 2, we continued our investigation with conducting hierarchical multiple regression analyses (HMR) the components of Subjective QoL (EORTC_QLQ_30): Physical_Functioning, Role_Functioning, Emotional_Functioning, Cognitive_Functioning, Social_Functioning, and Financial_Functioning. For each criterion variable, in the first step of the HMR, we introduced demographic variables (age, gender, marital status, and stage of illness). Next, we entered stepwise the components of Fear_Of_Cancer_Progression (Affective_Reactions, Partnership_Family, Occupation, Coping, and Loss_of_Independence). After running the regression analyses, we selected those variables which significantly predicted the above-mentioned components of subjective QoL. Preliminary analyses were conducted to ensure no violation of the assumptions of normality, linearity and homoscedasticity. Results are presented in Table 4.

Our results indicate that physical functioning was best explained by age [3.1%, F_(1,274) = 8.78, p = 0.003] and affective reactions of FOPQ [22.5%, F_(2,273) = 47.05, p = 0.000], together predicting 25.6% of the variance in EORTC_QLQ_C_30_Physical_Functioning. Role_functioning was significantly predicted only by loss of independence [F_(1,300) = 50.07, p = 0.001], explaining 14.3% of the variance in Role_functioning. Investigating the predictors of EORTC_QLQ_C_30_Emotional_Functioning, we entered in the first model affective reactions [F_(1,265) = 115.54, p = 0.001], which explained 30.4% of the variance [F_(1,265) = 115.54, p = 0.001]. In step two, we introduced coping [F_(2,264) = 62.68, p = 0.001], which predicted 1.8% of the variance in Emotional functioning, and in step three, the loss of independence component of FOPQ, resulting in a significant model [F_(3,263) = 46.35, p = 0.001], explaining an additional 2.4% of the variance, the three variables together explaining a total of 34.6% variance in emotional functioning. Regarding cognitive functioning, only one model proved significant [F_(1,277) = 35.71, p = 0.000], with FOPQ_affective_reactions explaining 11.4% of variance. Furthermore, FOPQ_Loss_of_Independence proved the only significant predictor in both the social functioning [F_(1,298) = 38.92, p = 0.001, explaining 11.6% of the variance], and financial difficulties [F_(1,297) = 46.96, p = 0.001, explaining 13.7% of the variance] components of subjective well-being.

Diagnosis with cancer and the associated side effects of treatment produce significant changes both in the lives of patients, and their environments (Singer, 2018). Over one-third of the cancer patients experience intense symptoms of psychological malfunctioning, which significantly affects the quality of their physical, personal, professional, social, spiritual lives (Holland et al., 2010; Grassi and Riba, 2012). These debilitating psychological states are often aggravated by a more specific kind of fear, namely, existential worries regarding the possible recurrence/progression of the oncological disease. Even if FoP is a normal, natural phenomenon, which may persist after remission and cessation of treatment (Wagner et al., 2011; Simonelli et al., 2017), in a considerable number of cases, it may attain extreme forms which may further affect the patients’ QoL (Simard et al., 2013).

The major aim of the present study was to conduct a more nuanced investigation regarding the relationship between different dimensions and intensities of FoP and facets of the QoL during the COVID-19 pandemic. This objective is strongly justified especially if we take into consideration the specific life-conditions created during the COVID-19 pandemic (frequent disruptions in the patients’ access to healthcare services, pending or suspended medical appointments, reduced access to financial resources due to severe economic restrictions, etc.), in a LMIC country as Romania, where the oncological care is frequently donor-dependent.

Our results indicate that less than a quarter of the sample experienced low, between 63 and 70% moderate, and 15% high levels of FoP.

The results of our study are in line with previous investigations (e.g., Waters et al., 2013) indicating a strong relationship between different levels of fear (related to family/partnership problems, occupation, illness, and loss of independence) and quality of life (QoL) in different dimensions (physical, role, emotional, cognitive, social, and financial) (Dunn et al., 2015; Ban et al., 2021). Our study found that higher levels of fear in cancer patients in different areas significantly decreased the quality of life in the corresponding dimensions. For example, higher levels of fear related to the disease resulted in a significant decrease in physical, role, emotional, cognitive, social, and financial dimensions of the QoL. Similarly, higher levels of fear related to loss of independence resulted in a significant decrease in physical, role, emotional, cognitive, social, and financial dimensions of the QoL, results that were similar with those provided by previous research (Ortega et al., 2020; Xiang et al., 2020; Bandinelli et al., 2021). Moreover, the effect size for the relationship between fear and QoL was moderate to large. The most significant effect size was observed for anxiety related to the disease and fear of losing independence.

Furthermore, our results also suggest that the affective component of FOPQ strongly correlates with all components of subjective well-being, including physical, role, emotional, cognitive, and social functioning, as well as financial difficulties. A similar association pattern was also observed in partnership/family and occupation, while the loss of independence shows stronger correlations with all components of subjective well-being. The coping component of FoPQ presented a weak but significant correlation only with financial difficulties. These results highlight the importance of considering the affective component of FOPQ in assessing subjective well-being and its various components.

Finally, our results suggest that physical functioning is significantly influenced by age and affective reactions of FOPQ, explaining 25.6% of the variance in physical functioning. Role functioning is only significantly influenced by the loss of independence, explaining 14.3% of the variance. Emotional functioning is significantly influenced by affective reactions, coping, and loss of independence, together explaining 34.6% of the variance. Cognitive functioning is only significantly influenced by affective reactions of FOPQ, explaining 11.4% of the variance. Social functioning and financial difficulties are only significantly influenced by the loss of independence, explaining 11.6 and 13.7% of the variance, respectively.

In conclusion, our study found a strong relationship between different levels of fear in cancer patients and quality of life in various dimensions, with higher levels of fear leading to a decrease in the corresponding quality of life, similar to the results presented in, e.g., Ban et al. (2021) study conducted during the COVID-19 pandemic, and Gotze et al. (2019) pre-pandemic investigation. The affective component of FOPQ was found to be strongly correlated with all components of subjective well-being, except for financial difficulties, which showed a weak correlation. The results also showed that physical, role, emotional, cognitive, social, and financial dimensions of the quality of life were influenced by different factors, with the most substantial influences being affective reactions, loss of independence, and coping mechanisms. Overall, the findings highlight the importance of considering fear in cancer care and its affective component in assessing subjective well-being and its various components.

In summary, the major conclusion of our study suggests that in the case of the assessed sample of Romanian cancer patienst during the COVID-19 pandemic, the quality of physical functioning is best predicted by age and affective reactions (25.5%), role functioning by loss of independence (14.3%), emotional functioning by affective reactions, coping, and loss of independence (34.6%), cognitive functioning by affective reactions (11.4%), social functioning by loss of independence (11.6%), and financial difficulties by loss of independence (13.7%). Our results may have high relevance not only in the specific socioeconomic context of Romania, but also in the COVID-19 conditions, especially if we take into consideration the uncertainty regarding the evolution of the pandemic and the imminence of crisis situations worldwide. Thus, we consider that these results may benefit prevention and intervention programs that target the enhancement the quality of life of cancer patinets.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving human participants were reviewed and approved by Institutional Review Board (IRB) approval 16.260/30.10.2020 by the Scientific Council of Babeș-Bolyai University of Cluj-Napoca, Romania. The patients/participants provided their written informed consent to participate in this study.

All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication. All authors participated in all phases of this work. ÉK and LD made a major contribution to this manuscript, FM made a medium contribution, and AM-F made a minor contribution. All authors reviewed the manuscript.

The research leading to these results received funding from the Ministry of Research, Innovation and Digitization grant, CNCS/CCCDI – UEFISCDI, project number PN-III-P1-1.1-TE-2019-0097, within PNCDI III.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.