Constructing a structural equation model of fertility anxiety, medical coping, and risk perception in cancer survivors

doi:10.21203/rs.3.rs-4108249/v1

This study aimed to explore the associations between fertility anxiety, medical coping, and risk perception in cancer survivors. We assessed 516 cancer survivors using fertility anxiety, medical coping, and risk perception scales. The score obtained for fertility anxiety was (63.227 ± 12.664); the score for the coping dimension was (21.114 ± 6.478); the score for the avoidance dimension was (16.680 ± 6.800); and the score for the submission dimension was (13.159 ± 4.674). The mean risk perception score was 39.949 ± 11.869. The structural equation model showed that risk perception had a negative role in facing (P < 0.001), and a positive role in avoidance, submission, and fertility concerns (P < 0.001). Avoidance and submission had positive effects on fertility concerns (P < 0.05), while facing had negative effects on fertility concerns (P < 0.05). Medical coping was a mediating variable between risk perception and fertility concerns. Fertility anxiety and risk perception were at a medium level among the cancer survivors assessed, with the participants more inclined to adopt a confrontational coping style. Medical coping can modulate the interaction between risk perception and fertility concerns.

Cancer

Fertility anxiety

Medical coping

Risk perception

Structural equation model

Reports from 2020 Global Cancer Statistics state that breast cancer and cervical cancer rank first in the incidence of female cancers worldwide and are also the main causes of death. They are marked by a high incidence and survival rate, and a young demographic trend [1–2]. Although cancer prevention and treatment methods are becoming increasingly mature over time, survivors still face economic pressure, the risk of cancer recurrence [3], fertility concerns [4], interpersonal tension [5], and a host of other associated problems. The rate for fertility concerns in cancer patients is as high as 57% [6]. This may be related to a lack of effective communication between doctors and patients, a lack of correct reproductive judgment, delayed participation in treatment decisions, and negative cognition of reproductive status [7–8]. The complexity of the medical process and patients’ uncertainty regarding their own conditions make risk perception ubiquitous among cancer patients and survivors alike, and even more prevalent than the actual risk of the disease [9]. Risk perception refers to individuals’ interoception, affect, and cognitive abilities regarding the various objective risks that exist in the outside world. This process emphasises the impact of an individual’s intuitive inferences and interoception on their perception [10]. Slovic [11] believes that risk perception is the objective risk generated by an individual's subjective processing of the outside world, which may be exaggerated, reduced, or even ignored. Even if the objective risk is very high, once the individual does not perceive it, it will not affect any of their subsequent activity. Cox [12] believes that individual behaviour has a corresponding goal and that risk perception occurs when individual behaviour is not aligned with the achievement of that goal. Cunningham [13] believes that the level of risk perception is affected by the uncertainty and consequences of behaviours. Therefore, we believe that individual risk perception affects individual cognition and attitude by influencing individual psychology, and thus has a hugely significant impact on individual behaviour.

Several previous studies have found that risk perception is inversely associated with the dimensions of facing diseases and positively correlated with the dimensions of submission and avoidance [14]. Medical coping refers to the conscious psychological strategies and behavioural responses produced by patients in the process of facing diseases. It is a relatively stable behaviour and is thought of as individuals’ response to sudden medical stress [15–16]. Studies have shown that although individual coping styles cannot effectively improve patients’ clinical symptoms, they greatly impact individual psychology; higher positive coping levels are associated with lower severity of the adverse consequences of stressful events [17]. Facing is a positive and effective coping attitude adopted by patients toward stressful events such as adversity. Avoidance and submission are a kind of compromise or negative reaction that will cause patients to experience negative emotions and escape psychology, and aggravate their anxiety and depression [18–21].

According to Zhang, the submission dimension of medical coping is positively correlated with fertility concerns, while the facing dimension is negatively correlated [22]. Fertility anxiety refers to a patient's concern about reproductive health and capacity, self-health, offspring's health, and parenting, including child-rearing and care. Logan et al.’s [23] study posits that fertility concerns are experienced in the process of cancer treatment from diagnosis to recovery, and psychological distress concerning fertility is widespread and persistent among cancer survivors. Subfertility in cancer survivors of reproductive age can contribute to psychological distress and mental health disorders, which can lower quality of life [24].

Based on the above literature review and the stress coping theory, as shown in Fig. 1, the following hypothesis is proposed: cancer survivors’ risk perception may interact with fertility concerns, and risk perception may directly or indirectly influence fertility concerns in cancer survivors through medical coping, as shown in Table 1. A structural equation model was used to explore the interaction path and relationship between risk perception mediated by medical coping as a mediating variable and reproductive anxiety. The aim of this study is to enrich the existing research regarding the psychological elements affecting the mechanism of reproductive anxiety in cancer survivors.

2.1. Research Goal

The research sample consisted of cancer survivors of childbearing age admitted to a tertiary hospital in Hengyang City, China. A convenience sampling method was used to select participants from September 2022 to March 2023. Inclusion criteria specified patients who (1) were diagnosed by histopathology as having had cancer for 1 year or more; (2) were female and aged 18–49 years; (3) were mentally normal, with an established level of reading comprehension ability; and (4) had provided informed consent and were able to cooperate. Exclusion criteria identified patients who (1) had a history of psychiatric disorders or mental illness; (2) were unaware of their own situation; and (3) were already deceased. This study was reviewed by the Ethics Committee of the First Affiliated Hospital University of South China (no. 4304070901517). The average age of the 516 cancer survivors was (33.75 ± 5.49) years. Regarding marital status: 446 of the study participants were married, 60 were unmarried, and 10 were divorced or widowed. 70 of the participants had 0 children, 156 had 1 child, 260 had 2 children, and 30 had 3 children. The types of cancer recorded among the study participants were: cervical cancer, 58 cases; endometrial cancer, 27 cases; ovarian cancer, 88 cases; thyroid cancer, 242 cases; breast cancer, 101 cases. In terms of the course of the disease: 334 participants had had cancer for 1 to 3 years, 98 for 3 to 5 years, and 84 for 5 years or more. In terms of the payment type used for medical expenses: 30 of the patients were self-funded, 264 relied on social medical insurance, and 110 relied on employee medical insurance.

2.2. Methods

2.2.1. Research tools

2.2.1.1. General information questionnaire

Information requested in this questionnaire included age (in years), course of disease (in years), marital status, being with or without children, number of children, education level, living status, cancer type, working status, residence location, personal monthly income (yuan), type of medical expenses payment, type of care, type of treatment; radiotherapy or chemotherapy, whether the cancer had recurred, whether the cancer had metastasised, and whether the respondent possessed a desire to reproduce.

2.2.1.2 Reproductive Concerns After Cancer (RCAC).

The scale employed in this study was formulated by Gorman et al. [25] and subsequently adapted into a Chinese version by Qiao [26]. This scale works to evaluate the reproductive concerns of female patients and encompasses 6 dimensions: spouse’s knowledge (3 items), pregnancy ability (3 items), pregnancy preparation ability (3 items), infertility acceptance (3 items), self-health (3 items), and child health (3 items), for a total of 18 items. The scale employs a five-point Likert scale ranging from strongly ‘disagree’ to ‘strongly agree’, respectively, with a corresponding 1–5 points. Under each dimension, a score of ≥ 3 points for any item indicates that the patient has a high level of reproductive concerns. The Cronbach's α coefficient of the scale in this study was 0.917.

2.2.1.3 Medical Coping Modes Questionnaire (MCMQ).

Shen and Jiang translated and revised this scale [27] to contain 3 dimensions, which are facing, avoidance, and submission. Higher scores suggested a greater inclination to adopt the corresponding coping mode. The MCMQ displayed acceptable internal consistency, with a Cronbach’s α of 0.749.

2.2.1.4. Risk perception.

This scale was compiled by Fang [28] and incorporates three dimensions: economic risk (four items), physical diagnosis and treatment risk (five items), and social psychological risk (three items). The scale consists of 12 items. Higher scores reflect a higher degree of risk perception. The Cronbach’s α coefficient of the scale in this study was 0.927.

2.2.2. Survey methods

Two highly experienced nurses from the hospital’s obstetrics and gynaecology department were asked to take on the role of investigators for this study. Before commencing the investigation, the nurses were provided with training for their role of investigators and appropriate assessments were conducted to ensure their preparedness. The nurses were made responsible for carefully selecting appropriate research participants. Upon obtaining informed consent from the research participants, the nurses then distributed the relevant questionnaires and provided unified instructions. The questionnaires were completed on site by the participants, collected immediately, and then reviewed to identify any missing or incomplete responses. Sample size = [max(number of dimensions)×(15–20)]×[1+(15%-20%)]. The maximum dimension was set to six, and 104–144 samples were calculated. To compensate for the potential loss of effective questionnaires, an additional 20% increase was required, bringing the total required sample size to 173 participants. Of the 552 questionnaires distributed, 516 were effectively recovered, with an effective recovery rate of 93.48%.

2.2.3. Statistical Methods

SPSS18.0 statistical software package was performed for all analyses. Count data were presented using frequencies and percentages, and the characterization of measurement data was performed using mean values and standard deviations. Using Pearson correlation analysis, this study investigated the correlation between reproductive concerns, medical coping modes, and risk perception in cancer survivors of childbearing age. AMOS26.0 software was used to set up the model and investigate the mediating effect among these three variables, with P < 0.05 considered statistically significant.

3.1. Status and relevance of fertility concerns in cancer survivors and medical coping, risk perception

The fertility anxiety scores of cancer survivors were (63.227±12.664); the scores of the dimensions of facing were (21.114±6.478); the avoidance dimension score was (16.680±6.800); and the submission dimension score was (13.159±4.674). The risk perception score was (39.949±11.869), with the correlation between fertility concerns, medical coping, and risk perception shown in Table 1.

3.2 Construction of structural equation models for fertility concerns, medical coping, and risk perception of cancer survivors

A structural equation model was constructed based on the medical coping, fertility concerns, and risk perception of the study participants, with the path coefficient of the model fitted using the maximum likelihood method. The operational results of the initial structural equation model are shown in Figure 2. The indicators of fit degree are as follows: c²/df=5.801, root-mean-square error of approximation (RMSEA)=0.079, goodness-of-fit index (GFI)=0.906, comparison of fit indexes (CFI)=0.872, incremental fit index (IFI)=0.873, Tucker-Lewis Index (TLI)=0.830, and adjusted goodness of fit index (AGFI)=0.853. According to the fitting standards, the RMSEA and c²/df failed to meet the fitting degree, which was corrected. The revised model is shown in Figure 3, where c²/df=3.930 (< 5); RMSEA=0.075 (< 0.08); GFI=0.944, CFI=0.923, IFI=0.924, TLI=0.897, AGFI=0.911 (> 0.8). The results of the path coefficients for fertility concerns, medical coping, and risk perception among cancer survivors are shown in Table 2. Risk perception had a negative response to facing (β=-0.203, P < 0.001), and a positive response to avoidance, submission, and fertility concerns (β=0.227, β=0.274, β=0.266; P < 0.001); avoidance and submission had positive responses to fertility anxiety (β=0.107, β=0.304; P < 0.05), while facing had a negative response to fertility anxiety (β=-0.106, P < 0.05). To explore the mediating effect between paths, the bootstrapping technique was used with 5000 samples; the standard for confidence intervals was 95%, and the deviation correction method was used for testing. The upper and lower intervals of risk perception → facing→ fertility concerns mediating path, risk perception → avoidance → fertility concerns mediating path, risk perception → submission → fertility concerns mediating path did not contain 0, and P < 0.001, so the mediation effect was established. The results are shown in Table 3.

4.1 Analysis of fertility concerns, medical coping, and risk perception among cancer survivors

In the present study, the aggregate score of fertility anxiety among cancer survivors was (63.227 ± 12.664), and was generally at a moderate level. These results are similar to those obtained in other comparable domestic studies [29–31]. The reasons for these similarities in results may be as follows: (1) the location of the cancers that form the study’s research objective directly involve the reproductive system, causing irreversible damage to it and creating subsequent fertility problems. (2) The median age of the population studied was (33.75 ± 5.49) years old, which is the golden age for reproduction and the main point of responsibility for taking care of the family and raising children. Influenced by traditional ideas, people regard their children as the continuation of their lives, and the infertility caused by cancer can create a strong psychological conflict with respect to their psyche. (3) Patients with gynaecological malignant cancer face the risk of cancer recurrence and a shortened life cycle, which creates a degree of uncertainty with regard to their ability to establish a healthy career, provide social support, and maintain family relationships. (4) In addition to long-term medical treatment, cancer survivors with reproductive needs also have to deal with follow-up fertility problems. Poor information channels and insufficient effective communication between doctors and patients will also inevitably increase the risk of psychological distress. (5) The heritability of cancer and the toxicity of the drugs involved in the treatment process make most survivors worry that the disease will be passed on to future generations and will affect the future health of their children.

The scores for the relevant dimensions in this study were (21.114 ± 6.478) for medical coping, (16.680 ± 6.800) for avoidance, and (13.159 ± 4.674) for submission, all of which were higher than the national norm [27], a finding that is similar to the results previously obtained by Ling [32]. This shows that the participants in this study were more inclined to adopt the coping style of facing when dealing with the stressful event of cancer, which can effectively guide the patients to correct their attitude, relieve pressure, and contribute to their physical and mental health. The reasons may be as follows: (1) most of the participants in this study had a strong marital status, a good husband-and-wife relationship, and warm family atmosphere, all of which are conducive to guiding patients to adopt positive and appropriate coping styles, and which help to alleviate the physical and mental impact of fear of recurrence. (2) In addition, most of the study participants had more than one child and faced less pressure to have and raise children. This is coupled with the fact that with the increasing maturity of medical technology, patients have more confidence in their treatment outcomes. Patients should be encouraged to actively express negative emotions they are experiencing to medical personnel, family members, and fellow patients as a positive means of coping, allowing them to actively adjust negative emotions to enhance their psychological adaptation level.

As a category of psychology, risk perception is the attitude, cognition, and view generated by an individual when facing a stressful event, which emphasises the impact of stressful events on an individual's intuitive judgment and subjective feelings. The scores for each dimension of risk perception assessed in this study from high to low were physical risk (16.713 ± 5.842), economic risk (13.173 ± 4.587), and social psychological risk (10.062 ± 3.540). The total score of risk perception was (39.949 ± 11.869), which was at the medium level, slightly higher than the results of foreign studies [33–34]. The likely reasons for this are as follows: (1) in the context of global informatisation, people have an increasing number of channels through which to obtain medical-related information, while their ability to discriminate information is limited. This is coupled with media exaggeration, meaning the lower the trust in the medical system, the greater the risk perception of patients. (2) Compared with economically developed countries, China's medical insurance system remains imperfect. The personal medical burden is still relatively high and many cancer patients spend their lifetime family income on disease treatment, while also fearing that the treatment will ultimately prove unsuccessful. The health belief model points out that, based on individual cognition and the surrounding environment, there will be differences in the perception level of disease risk. Even the real situation will often prove inconsistent with the actual risk of disease, which may cause the disease risk itself to be over or underestimated, leading to the deviation of individual behaviour [35–36]. Those who overestimate the risk of disease will be left in a chronic stress state for an extended period and will experience anxiety, depression, and other negative emotions that seriously damage their physical and mental health. However, underestimation of risk causes patients to ignore potential risks and react negatively, which is not conducive to follow-up monitoring and treatment of the disease [37–39]. Therefore, in clinical work, while also focusing on improving medical services and technology, medical staff should seek to strengthen disease knowledge education for patients, improve patients' cognitive levels, and promote the improvement of doctor-patient trust mechanisms. Mass media should seek to strengthen its degree of professional quality, objectivity, and truth with regard to reporting and publicity, and correctly guide the direction of public opinion. The government should increase financial input, improve the reimbursement system of social medical insurance, and promote and establish a reasonable and orderly hierarchical diagnosis and treatment model. Hospitals should provide reasonable diagnoses and treatments without excessive medical treatment, thus reducing patients' perceived economic risks.

4.2 Analysis of the interaction between reproductive anxiety and risk perception in medical coping of cancer survivors

The structural equation model constructed using the three variables included in this study: medical coping, risk perception, and fertility concerns is well-fitted. This verifies the hypothesis proposed in the literature analysis section above that risk perception may directly or indirectly influence fertility concerns in cancer survivors through medical coping. The output of the structural equation model revealed that: (1) the risk perception of cancer survivors had a favourable predictive effect on fertility anxiety; (2) risk perception was inversely associated with medical coping but was positively correlated with avoidance and submission; and (3) risk perception can not only directly affect fertility anxiety but also indirectly affect the fertility anxiety level of cancer survivors through the dimensions of facing, avoidance, and submission. This suggests that cancer patients can be effectively assisted in obtaining correct cancer risk information, can take the initiative to participate in the medical decision-making process, and can develop correct, reasonable coping strategies when facing risks, that can help to reduce their level of anxiety and depression. A negative response to cancer risk negatively affects individual health and hinders the implementation of cancer prevention and control measures [40].

Medical coping [41–42] is the coping style adopted by individuals when they encounter stressful events, such as adversity. It is a decisive and protective intermediate variable for psychological stress and health adaptation that can regulate patients’ adoption of different coping strategies during stressful life events. Different coping strategies will impact a patient’s state of physical and cognitive well-being to varying degrees, thus affecting the treatment and rehabilitation of the disease. Relevant studies have shown that although positive coping styles cannot completely relieve the discomfort of cancer survivors, they can significantly improve their psychological status [31, 43]. Negative coping styles will encourage patients to choose escape psychology, which will aggravate anxiety and depression and have a serious adverse impact on individual disease prognosis and health behaviour [44–45]. Therefore, it is desirable to formulate rational coping strategies to strengthen the enjoyment of the quality of life of cancer survivors.

Several factors affect fertility anxiety. Through a structural equation model, this study found that risk perception has a direct effect on cancer survivors’ fertility anxiety and that medical coping, as an intermediary variable between risk perception and fertility anxiety, can regulate the interaction between them. The findings of this study were that: (1) the path coefficients among the three variables assessed were not high. This analysis may be related to the subjective variables measured by the questionnaire; other important variables, such as emotional states (including anxiety and depression), cancer-related fatigue, and social support, were not considered in this modelling study. The prospective study should be conducted with a view to further supplement other important psychosocial factors affecting the fertility concerns of cancer survivors according to this theoretical framework. Additional sample sizes should also be made available, and the next verification of these research findings should be jointly carried out across multiple locations. (2) As a cross-sectional survey, this study only discussed the status quo mechanisms of cancer survivors' risk perceptions, medical coping, and fertility anxiety. Because these three factors are dynamically changing and developing, further longitudinal studies are required to explore their future development paths. (3) In addition, an evidence-based approach should be considered to explore validated intervention strategies to improve the degree of fertility anxiety in cancer survivors, pursue the best available evidence, and apply it in clinical care settings to ultimately benefit patients.

1.Ethics approval and consent to participate

This study has been approved by The First Affiliated Hospital University of South China Ethics Committee (No.4304070901517). All participants signed informed consent prior to the enrollment of this study. All procedures performed in accordance with the Declaration of Helsinki.

2.Consent for publication

Not Applicable.

3.Availability of data and materials

The datasets generated during and analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

4.Competing interests

The Author(s) declare(s) that there is no conflict of interest.

5.Funding

This study was supported by The Health Commission of Hunan Province (NO.202214034799)

6.Authors' contributions

Wu Xiaoqin: Conceptualization, Methodology. Peng Yejuan and Xiong Yuying: Data collection. Wu Xiaoqin Writing-Original draft preparation. Xun Rende:Writing- Reviewing and Editing. Ou Yan and Tong Mei: Data analyses. Zhou Yanhui: Supervision.

7.Acknowledgements

This study was supported by The Affiliated Hospital of University of South China and The Health Commission of Hunan Province.We thank all the study participants for volunteering to participate in this study.

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Table 1 Fertility concerns and medical coping, risk perception and correlation among cancer survivors（N=516）

	Fertility concerns	Medical coping			Risk perception
	Fertility concerns	Facing	Avoidance	Submission	Risk perception
Fertility concerns	1
Facing	-0.281**	1
Avoidance	0.302**	-0.446**	1
Submission	0.411**	-0.360**	0.443**	1
Risk perception	0.298**	-0.153**	0.165**	0.211**	1
Mean	63.227	21.114	16.680	13.159	39.949
Standard Deviation	12.664	6.478	6.800	4.674	11.869

note：*：P＜0.05。

Table 2 Path coefficient between fertility concerns, medical coping, and risk perception in cancer survivors

Regression pathway	β	b	S.E.	C.R.	P
Facing<---risk perception	-0.203	-0.486	0.118	-4.133	***
Avoidance<---risk perception	0.227	0.57	0.124	4.611	***
Submission<---risk perception	0.274	0.472	0.085	5.56	***
Fertility concerns<---Avoidance	0.107	0.033	0.015	2.19	0.029
Fertility concerns<---submission	0.304	0.134	0.021	6.365	***
Fertility concerns<---risk perception	0.266	0.202	0.042	4.809	***
Fertility concerns<---facing	-0.106	-0.034	0.015	-2.176	0.03

note：b: Non-normalised coefficient；β：Normalised factor coefficient；***，P＜0.001

Table 3 Mediating effects of fertility concerns, medical coping, and risk perception among cancer survivors

Mediating pathway	Effect size	SE	95% lower limit	95% upper limit	P
Risk perception→facing→fertility concerns	0.016	0.009	0.003	0.039	0.016
Risk Perception→avoidance→fertility concerns	0.019	0.010	0.002	0.043	0.031
Risk perception→submission→fertility concerns	0.063	0.016	0.036	0.101	0.000

No competing interests reported.

Constructing a structural equation model of fertility anxiety, medical coping, and risk perception in cancer survivors

Status:

Version 1

Abstract

Figures

1. Introduction

2. Objectives and methods

2.1. Research Goal

2.2. Methods

2.2.1. Research tools

2.2.1.1. General information questionnaire

2.2.1.2 Reproductive Concerns After Cancer (RCAC).

2.2.1.3 Medical Coping Modes Questionnaire (MCMQ).

2.2.1.4. Risk perception.

2.2.2. Survey methods

2.2.3. Statistical Methods

3. Results

4. Discussion

4.1 Analysis of fertility concerns, medical coping, and risk perception among cancer survivors

5. Conclusion

Declarations

References

Tables

Additional Declarations

Status:

Version 1