Accounting for 2.3 million new cases (11.7%) in 2020, breast cancer is regarded as the most common cancer in women and the leading cause of cancer death; nevertheless, the improvement of screening and treatment programs in recent decades has led to a considerable decline in breast cancer death rates. 12 Lately, attention has been directed to the effect of breast cancer and its treatment on psychological functioning and perceived quality of life. 3 Fear of cancer recurrence (FCR) is a special and highly conscious experience affecting emotional, cognitive and behavioral domains. According to recent systematic reviews of breast cancer survivors, 22% to 87% report moderate-to-high degree of FCR. 4 In view of such situations, patients, including those with breast cancer, are prone to life-threatening conditions, which may be accompanied by lasting and exaggerated anxiousness. 5 In fact, as one of the most common concerns and the biggest unresolved psychosocial problem of survivors, FCR affects the quality of life, including physical, mental, and social well-being, feelings of being healthy along with symptoms related to the disease or treatment. 67 FCR is coupled with anxiety, intrusive thoughts, rumination, and psychological distress, which pose increased risk of anxiety, depression, and maladaptive behaviors. 8 Therefore, understanding the psychological factors that contribute to FCR in cancer survivors would inform psychological interventions aimed at reducing this risk.

Cognitive emotion regulation can affect FCR, requiring a conscious and cognitive method to manage the intake of emotionally arousing information including adaptive strategies (putting into perspective, acceptance, positive refocusing, positive reappraisal and refocus on planning) and maladaptive strategies (self-blame, blaming others, rumination and Catastrophizing). 9 Emotion regulation by cognitions or thoughts helps people to control their emotions during or after experiencing threatening or stressful events. For example, when experiencing a negative life event, people may be inclined to blame themselves or others. They may concentrate on their feelings by ruminating or may accept or positively reappraise the situation. 9 Previous studies have revealed that maladaptive strategies lead to many psychological symptoms associated with cancer, including FCR. The studies have demonstrated the association between higher reappraisal as an adaptive strategy and decreased FCR 10 , and also habitual rumination as a maladaptive cognitive style to cope with high FCR. 8 Based on Leventhal's self-regulation model, illness perception involves domains of cognitive representation (consequences, timeline, identity (symptoms), control/treatment and causes of the illness), emotional representation as well as the extent of clear understanding of the illness. Illness perception shows the patient's perception of an illness either as harmless or threatening. 10 Research has demonstrated that illness representations affect FCR. 111213 Psychological well-being is a model of positive psychological functioning comprising six components: self-acceptance, environmental mastery, positive relations with others, purpose in life, personal growth, and autonomy. 14 Psychological well-being in cancer survivors is defined by the presence or absence of distress and the presence or absence of positive well-being and psychological growth. 15 As psychological distress is regarded as an aspect of FCR, the relationship between psychological wellbeing and FCR is fairly revealing. A study on women with breast cancer demonstrated a negative and significant relationship between psychological wellbeing and FCR. 16 Considering the dimensions of cognitive and emotional representation of illness perception, cognitive emotion regulation may be related to perceptions of illness. Cognitive restructuring as an adaptive strategy of cognitive emotion regulation can enhance illness perception. 17 Also, as the appraisal of positive and negative emotions exert effects on psychological well-being and considering that cancer patients undergo a wide range of negative emotions, emotion regulation can play a major role in their psychological well-being. 18 Therefore, based on the issues outlined above, in view of the relationships between the variables, illness perception and psychological well-being seem to be capable of mediating the relationship between cognitive emotion regulation and FCR. Researchers have yet to investigate the relationship between these variables in a structural model. Therefore, the study is to answer whether the structural model of FCR in breast cancer survivors, based on the cognitive emotion regulation and the mediating roles of illness perception and psychological well-being, fits with experimental data.

The study was a descriptive correlation. The population of this study included all women with breast cancer who were referred to Cancer Institute of Imam Khomeini hospital complex in Tehran for their regular checkups in the spring and summer of 2022. In the estimation of the sample size based on structural modeling, more than 200 people have been suggested. 19 Accordingly, 300 breast cancer survivors who satisfied the entry requirements were recruited based on convenience sampling. After providing necessary explanations about the study to participants and obtaining their informed consent, a link to the online questionnaire was sent to the respondents for completion.

Simard and Savard developed this inventory with 42 items in 2009, which consists of seven dimensions: triggers, severity, psychological distress, coping strategies, functioning impairments, insight, and reassurance. Each item is rated on a 5-point Likert scale ranging from 0 (never) to 4 (all the time). Simard and Savard estimated the reliability of this inventory equal to 0.95 based on Cronbach's alpha coefficient which indicates good internal consistency. 20 The validity and reliability of Iranian version of this inventory was confirmed by Bateni et al. The authors estimated Cronbach's alpha at 0.86. 21 In this study, Cronbach's alpha was 0.84.

Garnefski and Kraaij developed this short 18-item version in 2006, which consists of nine dimensions: putting into perspective, acceptance, positive refocusing, positive reappraisal and refocus on planning as adaptive strategies, self-blame, blaming others, rumination and Catastrophizing as maladaptive strategies. Each item is rated on a 5-point Likert scale ranging from 1 (never) to 5 (all the time). Garnefski and Kraaij estimated the reliability of this Questionnaire from 0.68 to 081 based on Cronbach's alpha coefficient. 22 The validity and reliability of the Iranian version of this questionnaire were confirmed by Mohsenabadi and Fathi-Ashtiani. The authors estimated Cronbach's alpha at 0.95 for adaptive strategies and 0.88 for maladaptive strategies subscales. 23 In this study, Cronbach's alpha was 0.82 for adaptive strategies and 0.77 for maladaptive strategies subscales.

Broadbent et al. developed this questionnaire with 9 items in 2006. The BIPQ measures cognitive representations (consequences, timeline, personal control, treatment control, identity), emotional representations (concern and emotions), illness comprehensibility and causes. Scores can range from 0 to 10 for each item, Patients choose the number that best corresponds to their views. Broadbent et al. estimated the reliability of this scale equal to 0.80 based on Cronbach's alpha coefficient. 24 The validity and reliability of the Iranian version of this questionnaire were confirmed by KarimiGhasemabad et al. The authors estimated Cronbach's alpha at 0.90. 25 In this study, Cronbach's alpha was 0.64 for cognitive representations and 0.75 for emotional representations.

Ryff and Keyes developed this short 18-item version in 1995, which consists of six subscales: selfacceptance, environmental mastery, positive relations with others, purpose in life, personal growth and autonomy. Each item is rated on a 6-point Likert scale ranging from 1 (strongly disagree) to 6 (strongly agree). 26 The validity and reliability of the Iranian version of this scale were confirmed by Khanjani et al. The authors estimated the reliability of this scale equal to 0.71 based on Cronbach's alpha coefficient. 27 In this study, Cronbach's alpha was 0.62.

Data were analyzed using Pearson's correlation coefficient to examine the relationship between variables, and Structural Equation Modeling (SEM) to examine direct and indirect effects of independent variable on dependent variable and the effect of mediating variables (model analysis). SPSS software (version 26) and AMOS software (version 24) were used for data analysis.

Overall, 300 patients participated in this study. The mean (± SD) age of patients was 44.06±7.52 years. Demographic and clinical data, consisting of age, education, job, and the duration of disease, are demonstrated in Table 1.

The mean (± SD) of variables for all participants and the correlation coefficients for the all dimensions of variables of study are presented in Table 2. Results showed the direction of correlation between the variables fulfilled the expectations and was in keeping with the theories of the study.

After the assumptions of normality data distribution, collinearity, and independence of errors were confirmed, the analysis of model was conducted. As Figure 1 illustrates, the latent variables of illness perception, psychological well-being, and FCR constitute the measurement model. It was assumed that the latent variables are measured through indicators as follows: psychological well-being by the indicators of self-acceptance, environmental mastery, positive relations, purpose in life, personal growth, and autonomy; illness perception by the indicators of cognitive representation, emotional representation, and illness comprehensibility, and fear of cancer recurrence by indicators of triggers, intensity, psychological distress, coping strategies, functioning impairments, insight and reassurance The fitting of the measurement model was assessed using confirmatory factor analysis, AMOS software (version 24), and maximum likelihood (ML) estimation. Table 3 demonstrates the fit indices of the measurement model and the structural model. Table 3 indicates that based on the cutoff points 29 except the CFI fit index (0.938, Cutoff Point: > 0.90), other fit indices which resulted from confirmatory factor analysis did not support the acceptable fit of the measurement model of the data collected. Consequently, the correction indices were evaluated and by creating the covariance between the errors the model was revised. Ultimately, the fit indices were obtained showing that the measurement model possesses an acceptable fit with the data collected.

Following the assessment of the fitting of the measurement model, the fit indices of the structural model at Stage 2 were estimated and assessed ( Figure 1). In the structural model, it was assumed that FCR in breast cancer survivors is affected by the adaptive and maladaptive strategies of cognitive emotion regulation directly and by the mediation of psychological well-being and illness perception. The structural model, being the focus of this study, was analyzed using the structural equation modeling method and the fit indices, as shown in Table 3, show the acceptable fit of the structural model with the data. Table 4 indicates the path coefficients of the structural model. The total path coefficient between adaptive strategies of cognitive emotion regulation and FCR (β=-0.449, P=0.001) is negative and significant, and the total path coefficient between the maladaptive strategies and FCR (β=0.490, P=0.001) is positive and significant. The path coefficient between illness perception and FCR (β=0.491, P=0.001) is positive and significant, and the path coefficient between psychological well-being and FCR (β=-0.294, P=0.001) is negative and significant. Table 4 indicates that the indirect path coefficient between the adaptive strategies of emotion regulation and FCR (β=-0.381, P=0.001) is negative and significant, and the indirect path coefficient between maladaptive strategies and FCR (β=0.321, P=0.001) is positive and significant. Table 4. Direct and indirect path coefficients between the variables in the structural model Table 5 indicates the mediating roles of psychological well-being and illness perception in explaining the effect of adaptive and maladaptive strategies of cognitive emotion regulation on FCR using Baron and Kenny's formula. 28 According to the results in Table 5, the indirect path coefficient between adaptive strategies and FCR through psychological well-being (β=-0.148, P=0.001) and illness perception (β=-0.233, P=0.001) is negative and significant. Additionally, the indirect path coefficient between maladaptive strategies and FCR through psychological well-being (P=0.001, β=0.109) and illness perception (β=0.212, P=0.001) is positive and significant. The results of this study revealed that psychological well-being and illness perception would negatively and significantly mediate the effect of adaptive strategies of cognitive emotion regulation on FCR, and positively and significantly mediate the effect of maladaptive strategies of cognitive emotion regulation on FCR. Table 5. The roles of psychological well-being and illness perception in explaining the effect of adaptive and maladaptive strategies of cognitive emotion regulation on fear of cancer recurrence Figure 1 shows that the sum of squared multiple correlations (R2) for FCR is equal to 0.61; this explains that the cognitive emotion regulation, psychological well-being, and illness perception account for 61% of the variance of FCR in breast cancer survivors.

High levels of FCR and its progression may persist over time and adversely affect mental health and quality of life, imposing a huge burden on health care resources. 29 Therefore, examining factors predicting and affecting FCR in patients is of outstanding importance. The purpose of this study was to examine and explain the effect of cognitive emotion regulation on FCR with the mediating roles of illness perception and psychological well-being in breast cancer survivors under a structural model we designed to examine the direct effect of adaptive and maladaptive strategies of cognitive emotion regulation and the indirect effect of them through the illness perception and psychological well-being on FCR. According to the results, the model demonstrated fitting to the data.

As to the direct effect of adaptive and maladaptive strategies of cognitive emotion regulation on FCR, the findings of this study correspond with the results of the studies of Guimond reappraisal, and cognitive restructuring-as adaptive strategies-have effectively decreased FCR in cancer survivors including those with breast cancer and gynecological cancer. 8303132 In a meta-analysis reviewing 23 studies on cancer patients, Taber et al. found that cognitive behavioral therapies focusing on cognitive processes such as worry, rumination, and attentional bias, whose objectives were to change how individuals relate to their internal experiences, had greater effects on reducing FCR. 33 Emotion regulation techniques which are employed by an individual do not substitute negative emotions for positive emotions, as the individual is still subject to negative emotions, but adaptive responses to the environment bring better results. 12 In view of the results obtained and their correspondence with previous findings, patients employing adaptive strategies think about joyful and pleasant issues instead of thinking about the actual event, assign a positive meaning to the event in terms of personal growth and accept what they have experienced; therefore they are more successful in controlling their emotions. Therefore, such strategies can contribute to controlling the key aspects of FCR and mitigate the effect of stimuli and situations resulting in FCR, fear intensity, and the period of time that a patient reflects on the disease recurrence, psychological distress caused by cancer such as sadness, despair, anger, and worry and personal and social functional disorder, whereas maladaptive strategies will increasingly lead to FCR.

As to the direct effect of illness perception on FCR, the results of this study correspond with those of other studies. In a study by Freeman et al., breast cancer survivors with more emotional representation of the experience and those who attributed unrelated symptoms to breast cancer were subject to more fear of the illness recurrence. 11 The findings of Shim et al. also revealed a positive relationship between fear of progression and components of illness perception such as consequences, timeline, identity, and emotions in individuals with breast cancer; However, in the multivariate regression analysis, only the timeline, identity and emotions predicted the fear of cancer progression. 13 The results of Zang's study also indicated that the perceived identity of the illness predicted psychological distress, which is one of the dimensions of FCR, in head and neck cancer survivors. 34 According to the scores for illness perception presented in the results section, including scores for cognitive and emotional representation as well as the correspondence of our findings with those of previous studies, those patients who believe that the disease may not have so great a bearing on their lives, and it will not last for a long time, may not experience certain symptoms and their disease is thus As to the direct effect of psychological well-being on FCR, the results of this study correspond with the study by Sharifi. 17 No other research has been done on the relationship between these two variables; nevertheless, considering the nature of fear, as a multifaceted factor, which is often one of the major factors in risking mental health and well-being, the findings of Tekir's study indicated that individuals whose fear of COVID-19 was lower than the average exhibited a higher than the average level of psychological well-being. 35 In another study, there was a significant positive relationship between the fear of COVID-19 and psychological distress and a significant negative relationship between the fear of COVID-19 with psychological well-being; psychological distress did mediate the relationship between the fear of COVID-19 and psychological well-being. 36 The results of our study and the findings of the above studies accordingly show the negative relationship between psychological well-being and FCR. As per our findings, where the patient exhibits an acceptable psychological well-being, despite constraints imposed by the disease, the patient demonstrates a positive attitude towards oneself and life, and actively involves in life activities and events, and explores meaning behind life's challenges and is also capable of managing life and its essentials; these aspects will result in a reduction in FCR dimensions such as psychological distress, worry and anxiety about the possibility of disease recurrence, and functional disorder in determining goals in life, daily tasks and social activities.

As to the direct effect of cognitive emotion regulation strategies on illness perception, the results of this study correspond with those of Hamzepour et al. who showed that changing thought processes through cognitive restructuring as an adaptive strategy resulted in the improvement of illness perception. 17 They are also in keeping with the results of a study on patients with chronic pain, demonstrating that there is a significant relationship between illness perception and poor strategies of cognitive emotion regulation, and that individuals having negative beliefs and threatening perceptions about their illness employ significantly maladaptive strategies such as self-blame and blaming others, and catastrophizing. 37 The direct effect of cognitive emotion regulation strategies on psychological well-being was shown to have been in line with the results of a study by Karbalie et al. who established a significant positive relationship between reappraisal, as an adaptive strategy, and psychological well-being in women with cancer and found an increase in their participants' psychological well-being 18 and the findings of Salajegheh et al. who reported that the adaptive strategies of cognitive emotion regulation affected psychological well-being in women with breast cancer 38 and the results of a study by Erisian et al. who demonstrated a change in the adaptive strategy of reappraisal is linked with a change in the psychological well-being of women with breast cancer. 39 The findings of a study by Balzarotti et al. have also emphasized the role of positive reappraisal and refocus on planning in contributing to adults' psychological well-being; as some cognitive emotion regulation strategies are more interconnected with emotional issues than others, the strategies may also affect the enhancement of the well-being of the individuals in different ways. 40 Employing adaptive strategies-especially acceptance of the disease, through putting into perspective and positive refocusing of the disease, patients consider their disease as more controllable; they undergo less anxiety; and finally display a less threatening perception of the disease. By exhibiting positive attitudes towards oneself and life, the patient will possess a higher psychological well-being.

Therefore, in addition to the direct effect of cognitive emotion regulation strategies on FCR, the indirect effect of them on FCR is elaborated by considering the effect of cognitive emotion regulation on illness perception and psychological well-being and the effect of these two variables on FCR.

The three variables of cognitive emotion regulation, illness perception and psychological wellbeing explained 61% of the variance in FCR in breast cancer survivors, highlighting the major roles of these variables in FCR. By and large, the results are confirmed based on the relationships between the variables of the study and their correspondence with the findings of previous studies.

According to the results of this study, cognitive emotion regulation strategies can affect FCR through influencing the perception of illness and psychological well-being. Breast cancer survivors who increasingly employ adaptive strategies of cognitive emotion regulation, have a less-threatening perception of their illness, and that those with higher psychological well-being exhibit less FCR. High FCR can negatively affect overall quality of life; therefore, psychological interventions for improving such factors are suggested in order to decrease FCR and increase quality of life in breast cancer survivors. Few studies have been conducted on FCR in Iran, hence further research is essential in the field of the psychological aspects of cancer especially FCR.

The study is limited for being cross-sectional, using self-report questionnaires, and limiting the samples only to Cancer Institute of Iran in Tehran; therefore, there is a need for similar studies in other cities using different samples.