The sequential mediating roles of psychological flexibility and maladaptive cognitive emotion regulation between illness perception and fear of cancer recurrence in gastrointestinal cancer patients

OBJECTIVES: Fear of cancer recurrence (FCR) is a prevalent source of psychological distress among patients with gastrointestinal cancer, yet its underlying regulatory mechanisms remain elusive. Grounded in Leventhal's self-regulation theory of illness, this study aimed to investigate direct and indirect effects of illness perception on FCR, focusing on the sequential mediating roles of psychological flexibility and maladaptive cognitive emotion regulation (MCER). METHODOLOGY: A two-wave questionnaire survey was administered to 243 patients with GI cancer, recruited from The Third Affiliated Hospital of Sun Yat-sen University. Validated instruments included the Fear of Progression Questionnaire-Short Form (FoP-Q-SF), Brief Illness Perception Questionnaire (BIPQ), Acceptance and Action Questionnaire-II (AAQ-II), and the maladaptive subscale of the Cognitive Emotion Regulation Questionnaire (CERQ). RESULTS: The mean score of FCR was 27.61 ± 8.50, with 26.7% of the participants reaching clinical significance (≥34 points). Illness perception exerted a direct positive effect on FCR (β = 0.532, p < 0.001) and three significant indirect effects through: (1) psychological flexibility (22.5% of the total effect, effect = 0.078), (2) MCER (12.1%, effect = 0.042), and (3) the sequential pathway of both the mediators (4.3%, effect = 0.015). Collectively, indirect effects explained 38.9% of the total variance. IMPLICATIONS: Psychological flexibility and MCER sequentially mediate the relationship between illness perception and FCR. These findings underscore the need to integrate cognitive-restructuring and psychological flexibility-enhancing techniques into clinical interventions for FCR reduction. Longitudinal designs and multi-center samples are warranted to strengthen generalizability.