Fear of Cancer Recurrence Care: What Clinicians Say Is Feasible

Stepped-care treatment elements of a clinical pathway for fear of cancer recurrence (FCR) were rated feasible by most Australian health professionals and researchers, whereas resource-intensive recommendations, such as training all clinical staff to screen for FCR, drew the least support, according to a Delphi study published in Supportive Care in Cancer.

Feasibility ratings for individual pathway elements ranged from 49.4% to 90.1%, and staffing, funding, and workflow limitations were the most frequently cited barriers to putting the pathway into routine practice.

Fear, worry, or concern about cancer coming back or getting worse affects most people with cancer to some degree. An individual participant data meta-analysis of 9311 people found that 39% experience moderate FCR and 19% experience severe or clinical FCR. Help with FCR has been identified as the greatest unmet supportive care need among people with cancer, yet evidence-based screening tools and treatments are rarely implemented in routine care, the investigators wrote.

How was the fear of cancer recurrence pathway evaluated?

The analysis is a secondary analysis of a 3-round online Delphi study that established consensus on an optimal clinical pathway for identifying and managing FCR in early-stage cancer survivors. The pathway includes routine FCR screening, further assessment and triage, and stepped care across 3 levels: universal care for minimal to mild FCR (step 1), supported self-management for moderate FCR (step 2), and specialist care for severe FCR (step 3).

Of 94 individuals who consented, 89 completed round 1 (April-June 2023), 69 completed round 2 (July-August 2023), and 73 completed round 3 (November-December 2023). Participants were primarily clinicians (86%), including nurses (n = 30; 32%), mental and allied health professionals (n = 31; 33%), and medical, radiation, or surgical oncologists (n = 18; 19%). Most worked in metropolitan settings (84%).

Participants rated the feasibility of each pathway element, defined as the likelihood of implementation in routine care, on a 5-point Likert scale. Open-ended comments were coded to the updated Consolidated Framework for Implementation Research (CFIR), and implementation strategies were matched to the most common barriers and enablers using the CFIR-Expert Recommendations for Implementing Change (ERIC) matching tool.

Which parts of the pathway were rated most and least feasible?

The highest-rated element was the statement that all health care professionals should validate and normalize FCR (90.1%). The lowest-rated element was training all clinical staff to implement FCR screening and respond appropriately (49.4%).

Average feasibility by pathway component was:

• Post-screening/triage stepped-care treatment: 75.9%
• Triage, assessment, and referral: 71.4%
• Step 3, specialist care for severe FCR: 69.0%
• Screening: 66.8%
• Step 1, universal care for minimal to mild FCR: 64.4%
• Step 2, supported self-management for moderate FCR: 61.0%

Several elements bear directly on nursing roles:

• Non-mental health specialists, such as cancer care nurses and coordinators, are well placed to hold triage conversations: 73.3% feasible
• Training is needed to support triage conversations about FCR: 83.7%
• Oncology specialists and nursing staff are the ideal people to address mild FCR as part of routine care: 60.5%
• With further training, oncology nurses and other clinicians without specialist psychology training could deliver interventions for moderate FCR: 50.8%
• A triage conversation should take place with all cancer survivors: 53.6%
• Patient education is needed to encourage uptake of recommended FCR interventions: 84.9%

Use of a brief validated screening tool was rated feasible by 84.3%, and a 2-step screening process, with a brief initial tool followed by a longer measure of severity, by 67.4%. Feasibility ratings were consistently lower than optimality ratings for the same elements, which the authors described as tension between what is best for patients and what providers can realistically deliver.

What barriers and enablers did clinicians identify?

Of 639 open-ended responses, 410 related to elements included in the final pathway; 170 were coded as barriers, 154 as enablers, and 53 as neutral. Most barriers fell within the inner setting, or organizational context (91 barriers).

The most frequently coded barriers were available resources (n = 31) and work infrastructure (n = 30). Participants reported that most social workers and psychologists would be unable to take on FCR work without funded hours, and that access to mental health specialists was particularly limited in regional, rural, and remote areas. Limited time and workload were also cited as barriers to screening opportunities in clinic (n = 15). One participant wrote, "Not all clinical staff have the time or capacity to do this [FCR screening] in their clinic."

Work infrastructure was also the most frequently coded enabler (n = 35), largely through the use of non-mental health specialist staff for screening and triage to address workforce gaps. As one participant put it, there are "always more nurses than psycho-oncology staff." Other enablers included responsiveness of the pathway to patient needs (n = 25), adaptability to local contexts (n = 22), and access to knowledge and information through training (n = 21). Participants noted that modular online training may be sufficient to support triage conversations.

What implementation strategies do the authors recommend?

Strategies matched to the identified barriers and enablers included educational meetings and tailored, modular training across health professional roles; identifying and preparing local champions; tailoring delivery to local resources and patient populations; engaging patients and families in shared decision-making; building coalitions that extend beyond cancer centers; securing implementation funding; and aligning pathway components with existing workflows.

The authors suggested that prioritizing high-impact elements, such as training selected staff to screen and focusing triage on survivors with moderate to severe FCR, may improve feasibility in resource-limited settings. They also noted that automated electronic patient-reported outcome measure administration could reduce the complexity of 2-step screening, and that trained lay navigators, including people affected by cancer, could help identify survivors with FCR and connect them with services. Prior research cited by the authors found that 99% of clinical and psychosocial professionals were interested in FCR training, although uptake of online training for a similar pathway was 7%.

ONN has previously reported on the role of nurses in normalizing FCR after treatment and on patient perceptions linked to higher fear of recurrence.

What are the key takeaways for oncology nurses?

• Nurses are central to the pathway's workforce model. Participants viewed cancer care nurses and coordinators as well placed for triage conversations, and nursing staff as a resource where psycho-oncology staffing is limited.
• Validating and normalizing FCR was the most feasible element rated (90.1%) and can be part of any patient encounter.
• Training is a prerequisite. Training to support triage conversations was rated feasible by 83.7% of participants, while delivering interventions for moderate FCR without specialist psychology training drew 50.8% support.
• Screening timing matters. Some participants noted that screening immediately before a follow-up appointment may capture temporary spikes in fear rather than persistent FCR.
• Shared decision-making supports engagement. Participants emphasized patient choice among self-management and clinician-delivered options within stepped care.
• Access is uneven. Survivors in regional, rural, and remote areas may face limited access to psychology services, and options outside the hospital setting may be needed.

References

1. Smith B, Wu VS, Pearce A, et al. Designing for delivery: a Delphi study of feasibility-informed implementation strategies for a fear of cancer recurrence clinical pathway. Support Care Cancer. 2026;34:1079. doi:10.1007/s00520-026-11275-9
2. Luigjes-Huizer YL, et al. What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis. Psychooncology. 2022;31(6):879-892.
3. Smith AB, Girgis A, Taylor N, et al. Step-by-step: a clinical pathway for stepped care management of fear of cancer recurrence—results of a three-round online Delphi consensus process with Australian health professionals and researchers. J Cancer Surviv. 2026;20:766-780. doi:10.1007/s11764-024-01685-1
4. Benyon B. Patient perceptions, other factors linked to fear of recurrence. Oncology Nursing News. February 19, 2021. Accessed October 15, 2026. https://www.oncnursingnews.com/view/patient-perceptions-other-factors-linked-to-fear-of-recurrence