In this study, the presence of uncontrolled physical symptoms, psychological distress, and poor HRQoL was associated with high FCR in stomach cancer survivors even after adjusting for covariates. Functional social support and satisfaction for communication within the medical team and care coordination were negatively associated with the FCR. However, FCR was found to have no relationship with cancer–related or socio-demographic factors, except age and health promotion or disease prevention activity of stomach cancer survivors.
Like other cancer patients, stomach cancer survivors who are younger, with uncontrolled physical symptoms, psychological distress, and lower HRQoL were associated with higher FCR . In a previous study with 342 Chinese breast cancer survivors who were diagnosed less than 2 years (67.3% of the total number of subjects), between 2 and 3 years (14.0%), and more than 3 years (18.7%), no religious beliefs, lower family income, and treatment modality (breast-conserving surgery) were associated with the higher level of FCR, unlike our result . The differences in our FCR effects may be due to the diagnosis period; this study has a long time (average of 7.3 years) since its diagnosis. In general, breast cancer patients are often easily affected by psychological and social factors and have a higher level of FCR . We confirmed the relationship between social supports, social and emotional quality of life, and levels of FCR in stomach cancer survivors. Because social support was related to predicting mood, coping strategies, and positive adjustment in cancer survivors [25–27], it should be considered in understanding FCR. But it has to be interpreted with caution as different results may be arisen depending on cultural differences of a family-dependent nature, age, perceived support level, or family roles [27, 28].
Null associations were identified for gender and education level in this study. In Canadian patients with breast, prostate, lung, and colorectal cancer, the FCRI for female cancer survivors was high . However, this finding did not hold after controlling for the cancer type. Although further research is needed when there is not enough gender-specific research, the systematic review of 43 studies reported that gender appeared unrelated to FCR . However, recent studies of hematologic cancer patients, including 467 Korean lymphoma patients, reported that female patients had a greater FCR than male patients [28, 30]. Stomach cancer is one of the cancers with a good survival rate. Since 85% of the study participants were stage 1 or 2, the five-year survival rate is increased up to 97.4% in 2017 . On the other hand, the five-year survival rate of the Korean non–Hodgkin lymphoma patients is 63.8 % in the same year . We thought that there may be a gender gap of FCR because a relatively poor prognosis can be vulnerable to emotion [28, 31]. Regarding the relationship between education and FCR, FCR was associated with a lower education level in 89 American breast cancer patients . There was a suggestion for the role of education that highly educated patients may have a greater understanding of the implications of cancer diagnosis . However, the lack of relevance between FCR and education levels in this study is that the role of education may have been relatively insignificant as long-term survivors who do not need the understanding of cancer diagnosis.
Several studies revealed no association between FCR and the influence of treatment type and duration, and stage of the disease [10, 28]. However, physical and psychological symptoms, such as fatigue, pain, sleep problems, distress, anxiety, and depression, were strongly associated with FCR regardless of cancer type or time since cancer diagnosis . We suggest that this is also due to the nature of FCR in long-term survivors of cancer on the effect of uncontrolled physical and psychological symptoms [6, 10, 24]. Therefore, continuing interest to control their physical and psychological problems is important in aspects of both FCR management and care coordination .
It was a noticeable finding that FCR was associated with the satisfaction of care coordination in stomach cancer survivors, which is compatible with the findings of a previous study in 2,290 non–metastatic multi-ethnic breast cancer patients . Well-coordinated care may reflect a good relationship between patients and healthcare providers. A provision of proper coaching or strategies for FCR from the healthcare providers would have lowered the level of FCR . Additionally, whole-person care and tailored patient education for lifestyle modification may reduce the development of comorbidities and prevent late adverse effects after cancer diagnosis .
However, survivors’ health promotion and disease prevention activities were not associated with the level of FCR in this study. Even in survivors with high FCR, lifestyle modification, secondary primary cancer screening, and surveillance of comorbidities were unaffected. These findings do not support the ‘teachable moment theory,’ suggesting that cancer survivors who experience greater FCR are motivated to engage in health behaviors [11, 35]. This theory has worked in the case of smoking cessation . However, the theory does not apply to the health behaviors of cancer survivors because FCR severity may neither encourage nor hinder most survivors . Cancer survivors with high FCR may experience high levels of distress and may not adhere to healthy lifestyle recommendations . For example, a study in the United States found that survivors of breast, gynecologic, colorectal, and non-melanoma skin cancers with high FCR were twice more likely to smoke as those with no FCR and didn’t do enough exercise (half an hour or more at least five times a week) . To explain this, we propose the following: that most cancer survivors try to improve their health behaviors regardless of the level of FCR. The practice of healthier habits defined as any positive activities concerning cancer or treatment was found to have doubled after cancer diagnosis regardless of the level of FCR in US survivors . Additionally, the rate of unhealthy behaviors in our study was too low to compare for significant differences across the different FCR groups; the proportion of current smokers in our study was much lower (0.4%) compared to that (14%) of the United States study . Last, the effect of FCR on health behaviors may be motivational for a certain period of time only or during a treatment period. It was known that FCR stabilizes over time . Therefore, there was no association between FCR and health promotion and disease prevention activities for long-term survivors . Unfortunately, we did not find the variance between time since diagnosis and FCR in this study.
The present study has some limitations. First, our study results may not be generalizable to all stomach cancer survivors because this study was conducted in one academic hospital. However, this hospital is involved in cancer care for more than 10% of all Korean cancer patients. Many cancer patients in South Korea have been conducting regular medical examination at the hospital, taking gastrectomy for more than five years . Second, this study was conducted using a cross-sectional study design with information collected simultaneously; we cannot ensure the time relationships between FCR and satisfaction of communication and care coordination and health promotion and disease prevention activities. Third, we assessed HRQoL, physical and psychosocial factors, and health behaviors through self-report questionnaires. Data are susceptible to recall bias and bias due to social desirability because of non-objective observation . Fourth, we could not compare the effect of treatment modality, e.g., endoscopic treatment and surgical treatment, on FCR, because the number of patients receiving endoscopic treatment was small (n = 6). In a previous study, endoscopic treatment of early esophageal cancer had a less negative impact on the quality of life and physical symptoms than open surgery . Considering the effect of uneven treatment status, our participants were limited to stomach cancer survivors with gastrectomy. Last, it was not clear whether distinguishing FCR levels from tertile value of FCRI meant actual clinical FCR because there was no known cut–off value of FCRI. Although the FCRI-short form including nine items, presents 22 points as cut–off, experts have said that this value may not be applied to other populations of cancer survivors. Therefore, further study was needed to explore the clinical cut–off points in Korean stomach cancer survivors.
Nevertheless, this study is the first to study to evaluate the related factors with FCR in stomach cancer survivors and has the strength to consider a wide range of factors, including clinical and socio-demographic characteristics, physical symptoms, psychological distress, and quality of life.