Introduction

Colorectal cancer (CRC) is a common diagnosis, ranking as the third most common cancer in the US [1]. The American Cancer Society [2] estimates that in 2024, there will be 106,590 colon and 46,220 rectal cancer cases diagnosed in the US, with an expected 53,010 deaths from CRC. However, due to advances in early diagnosis and treatment, CRC-related mortality rates have been gradually declining [1]. Notably, the rate of young-onset CRC, diagnosed before the age of 55, has been increasing over the past two decades for unknown reasons [2, 3]. According to the American Cancer Society report, since the mid-1990s, the incidence of CRC has risen by 1% to 2% annually in individuals under 55 [2]. As a result, a growing number of survivors are expected to live longer while dealing with the effects of their disease and treatment, such as increased levels of anxiety.

According to a recent meta-analysis, the pooled prevalence of anxiety symptoms in CRC patients was 18.9% [4]. Excessive anxiety in any cancer patient is concerning as it is associated with increased disease complications, treatment issues, and mortality rates. A US-based prospective cohort study involving 1228 health professionals diagnosed with CRC found that increases in anxiety symptoms correlated with a 17% higher mortality risk, even after controlling for cancer characteristics [5]. Therefore, understanding the factors associated with anxiety within the CRC population is crucial for its effective prevention and treatment.

Despite numerous recent findings in this research area, no scoping review specifically focusing on anxiety in the CRC population has been published. Some systematic [6, 7] or literature reviews [8] exist, though these address narrower research questions such as the onset [6] or prevalence of anxiety [8], or the predictive value of anxiety on the mortality of patients with CRC [7]. However, these reviews often exclude findings that would provide a broader view of this phenomenon. In addition, while the existing literature contains several comprehensive review articles on anxiety in cancer patients as a generalized group [9,10,11,12,13,14], there are few that specifically address anxiety in CRC patients. Synthesizing findings on anxiety in specific types of cancer is crucial, as each cancer type exhibits unique characteristics in terms of disease progression and treatment modalities. CRC patients often experience unique anxiety-related factors that differentiate them from other cancer patients, such as social isolation resulting from bowel or ostomy problems [15, 16]. The primary purpose of this scoping review is to synthesize and compile findings on the factors associated with anxiety in CRC patients. By analyzing the current literature, our goal is to identify risk factors and consequences of anxiety in CRC survivors, as well as the instruments used for assessment. Through this, we aim to pinpoint the current research gaps concerning anxiety in this population.

Methods

We followed Arksey and O'Malley's [17] methodological framework for this scoping review. The research process was initiated with an initial article search in November 2023, in consultation with a health sciences librarian. To ensure that our research was up to date and included the most recent information available, we conducted a final follow-up search in April 2024. We utilized four key databases for the search: CINAHL, PubMed, PsycINFO, and Scopus. Our search strategy was carefully crafted to capture a broad range of articles related to anxiety and colorectal cancer. The specific query used was: ((anxiety[Title/Abstract]) AND (colorectal[Title/Abstract] OR colon[Title/Abstract] OR bowel[Title/Abstract] OR rectal[Title/Abstract])) AND (cancer[Title/Abstract] OR neoplasm*[Title/Abstract] OR carcinoma*[Title/Abstract] OR tumor*[Title/Abstract]).We included articles with ‘colorectal cancer’ and ‘anxiety’ keywords in their title or abstract, published in English between 2013 and 2024. We limited our search to this period to collect the most current research on this issue. We excluded studies where CRC or anxiety was not the major subject (e.g., mixed results with other cancer populations or other mental health outcomes like depression), those solely evaluating specific intervention aspects (e.g., surgical technique, cognitive behavior therapy), or studies centered on colorectal cancer screening.

Our selection process is visualized using a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram (see Fig. 1). At the initial stage of our process, a total of 1616 studies were identified as potential sources for our review. Using Covidence, we identified 601 duplicate studies to remove from our pool. We also manually identified an additional 14 duplicates, further refining our pool. After eliminating these duplicates, we were left with 1001 studies. After reviewing titles and abstracts, we excluded 916 studies that did not meet our prespecified criteria for inclusion. We then reviewed the full text of the remaining 85 studies, leading to the exclusion of 34 additional studies. The reasons for their exclusion varied, including issues such as unsuitable mixed samples (e.g., results related to anxiety were mixed with those of other cancer populations or individuals without a cancer diagnosis) or unsuitable study design (e.g., results related to anxiety were combined with other mental illnesses such as depression, or studies where anxiety is not the focus) (Fig. 1). After this comprehensive review and exclusion process, 51 studies met our specified criteria and were included in our review.

Fig. 1
figure 1

PRISMA for anxiety among colorectal cancer survivors

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The data charting process for this scoping review involved extracting key information from each included study. The extracted data items included the authors and year of publication, study design, the country where the study was conducted, cancer site, stage of cancer at the time of the study, sample size, exclusion of participants with a mental health history, study timeframe, measures used to assess anxiety, cut-off points used in these measures, identified risk factors for anxiety, and the consequences of anxiety as reported in the study.

Results

The included articles comprise three review papers, 43 quantitative studies (including 22 cross-sectional and 21 longitudinal studies), four qualitative studies, and one mixed-method study. These studies were conducted in various countries, with the majority in the US (n = 12) and China (n = 10), including Brazil, Spain, the Netherlands, and Japan. The characteristics of the included studies are summarized in Table 1. In addition, this table categorizes variables into two groups: risk factors and consequences of anxiety. We consider independent variables as potential risk factors and dependent variables as potential consequences. We also consider timely sequences or mechanistic plausibility, such as gender being a risk factor of anxiety, not the other way around. The interpretation of results within the studies also significantly influences our classification process. However, it is important to note that due to the observational nature of most included studies, our ability to confidently establish a clear cause-and-effect relationship, or even directionality, between anxiety and the other variables is inherently limited.

Table 1 Included study characteristics, anxiety risk factors, consequences and assessment instruments
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We classified data on risk factors into six domains using Niedzwiedz et al.’s [10] framework, designed to explain factors contributing to depression and anxiety among cancer patients. The framework considers individual characteristics, social/ contextual factors, prior psychological factors, psychological responses to diagnosis, characteristics of cancer, and treatment [10]. We modified the 'psychological responses to diagnosis' domain to 'psychological responses to diagnosis and treatment', as most psychological factors in our included studies were evaluated during or after treatment.

Based on data extracted from the included studies, we summarized the risk factors and consequences of anxiety in CRC survivors in Table 2. The consequences of anxiety in survivors of CRC were multifaceted and could be divided into three categories: global health status/quality of life, functions, and symptoms/problems. These categories were derived from the subcategories of the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire-C30 (EORTC QLQ-C30), a quality-of-life instrument for cancer patients [63, 64]. In this instrument, a high score for the global health status or quality of life represents a high quality of life. A high score on a functional scale indicates a high or healthy level of functioning. Lastly, a high score for a symptom scale or item indicates a high level of symptomatology or problems. We modified ‘symptom scales/items’ to 'symptoms/problems’. If studies had outcome variables not assessed by the EORTC QLQ-C30, we categorized them according to their closest relevance with items of this instrument under each category.

Table 2 Risk factors and consequences of anxiety in colorectal cancer survivors
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Risk factors associated with anxiety in CRC survivors

Individual characteristics

While a few studies found no significant connections between the burden of comorbid health conditions and anxiety [5, 54], the majority revealed that CRC survivors with more comorbid health conditions typically have higher levels of anxiety [5, 6, 23, 25, 33, 45]. A prospective cohort study in the US involving 1228 health professionals suggested a link between poorer cardiometabolic health and clinical anxiety levels in females with CRC [5]. However, this link was not observed in male participants [5].

Researchers have found that certain lifestyle and behavioral characteristics of CRC survivors are associated with anxiety levels. For example, alcohol consumption [48] and moderate-to-vigorous physical activity [56] were linked to lower anxiety levels. However, studies have yielded mixed results on the connection between smoking and anxiety levels [29, 61]. A cross-sectional study in the UK found that current smokers had higher odds of anxiety cases than those who never smoked [29]. Conversely, a longitudinal study in China discovered that current smoking was an independent factor associated with a lower risk of anxiety over three years [61]. Additionally, a cross-sectional study found that participants who were overweight or obese had lower anxiety [23]. A study in Spain evaluated the anxiety levels and nutritional status of CRC patients before surgery, revealing that those with high anxiety levels were more likely to be malnourished compared to others [52].

Social & contextual factors

Gray et al. [29] measured the social difficulties of 496 CRC survivors using the Social Difficulties Inventory (SDI). Their study explored the relationship between these social factors and the levels of anxiety. The findings showed that participants with more social difficulties were more likely to have anxiety. In addition to this study, numerous others (see Table 2) have demonstrated the influence of various social/contextual factors on anxiety among CRC survivors. For instance, employment status has mixed results: some studies found lower anxiety in employed survivors [29, 61], others found higher anxiety [22, 23], or no significant association [30, 65]. Lower anxiety was noted in those with social support [23, 65] and cancer self-disclosure [54]. Higher anxiety was linked to discrimination or loneliness [22, 23].

A qualitative study in Norway involving nine adults recently diagnosed with stage I–III rectal cancer offered more contextualized insights into anxiety in CRC survivors [49]. The participants reported that grief, anxiety, and depression triggered by life events before their cancer diagnoses had significantly more disruptive effects than their cancer itself. These events included the loss of close relatives or loved ones from illness or serving as long-term caregivers for their ill loved ones for years [49].

Prior psychological factors

Studies have found that the psychological factors of CRC survivors before their diagnosis influence their anxiety levels after diagnosis. In a UK-based cross-sectional study involving 496 CRC survivors, individuals who reported a history of anxiety or depression on a patient-reported co-morbidities questionnaire were significantly more likely to be classified as anxiety cases compared to those who reported no such history [29].

In Greece, a prospective cohort study involving 852 individuals diagnosed with rectal cancer yielded interesting findings [60]. The researchers used the 14-item Type D Personality Scale (DS14) to classify the participants' personality types. They discovered that patients identified as having a Type D personality, characterized by increased negative affectivity and social inhibition, experienced notably higher levels of anxiety at the time of diagnosis and six months later compared to those with a non-Type D personality [60].

Psychological response to diagnosis and treatment

Regardless of the cancer type, fear of recurrence is a common psychological response among survivors. Through interviews with CRC survivors who had completed treatment, Carlile and McAdam [16] reported that this fear, or the worry that something was “ not right” [16, p. 100], caused anxiety among the study participants.

Several longitudinal studies have investigated the correlation between participants' baseline anxiety before CRC surgery and their anxiety levels at follow-up. In Spain, Gonzalez-Saenz de Tejada et al. [28] assessed the anxiety levels of 947 CRC patients before surgery and one year afterward. They found that participants with higher anxiety levels prior to surgery reported a more significant decrease in anxiety levels after one year. Orive et al. [46] assessed the anxiety levels of 2531 CRC patients before surgery, and at one, two, three, and five years post-surgery. Study findings showed that participants with high anxiety levels before surgery reported high anxiety levels even after five years.

CRC survivors utilized a variety of coping strategies to handle the burden of cancer and its treatment. While many strategies helped to mitigate anxiety, some were associated with increased anxiety over the long term. For instance, meaning-making, acceptance, and participating in support groups were associated with reduced anxiety [39]. However, both active and passive avoidance, as well as denial, were associated with increased anxiety in the long term [22, 39]. Interestingly, a cross-sectional study involving 353 heterosexual and 127 sexual minority CRC survivors found that attending a cancer support group or using active coping strategies was associated with greater anxiety [23].

Characteristics of cancer

Research shows mixed results regarding the relationship between the time since diagnosis or treatment and anxiety. While some studies find no significant variation in anxiety over time [31, 45], others report either a decrease [25, 36, 37, 40] or an increase [35, 61] as time progresses. For instance, Howren et al. [32] conducted a retrospective cohort study in Canada and found that CRC survivors displayed the highest anxiety rate during the continuing phase, which is between 12 months after CRC diagnosis and 12 months before cancer death. On the other hand, Lloyd et al. [40] found the highest rates of anxiety within two years of a cancer diagnosis in their retrospective cohort study using the Utah population database. Additionally, a longitudinal study from China reported a consistent increase in anxiety rates from discharge to three months post-discharge [61]. In addition, a different longitudinal study in China revealed that the anxiety level among rectal cancer patients decreased 1–2 days before hospital discharge compared to 1–2 days before surgery [37].

In Brazil, Miranda et al. [41, 43] published consecutive study findings examining the association between proinflammatory cytokine levels and anxiety or depression. Their study findings revealed that higher levels of IL-1β, IL-6, IL8, or TNF-α were associated with higher levels of anxiety, while lower level of IL-10 was associated with higher levels of anxiety. Furthermore, Miranda et al. [42] found that Fractalkine serum level was also positively associated with anxiety level. Moreover, a prospective cohort study conducted in the Netherlands found that in confounder-adjusted linear mixed models, higher concentrations of 3-hydroxyanthranilic acid were associated with lower anxiety scores [31]. However, in sensitivity analyses, this association did not remain statistically significant after FDR adjustment.

Cancer treatment

Research has revealed a significant association between CRC survivors who have undergone radiotherapy, chemotherapy [6, 23, 33, 46]. or ostomy surgery [6, 19, 51] and increased anxiety levels. However, Mols et al. [45] found no significant association between radiotherapy or chemotherapy and anxiety levels in their prospective cohort study in the Netherlands. Regarding different types of ostomies, the results also vary. While Song et al. [51] found no significant difference in anxiety levels between participants with temporary or permanent ostomies, Hu et al. [33] found a higher risk of anxiety in participants with permanent ostomies compared to those with temporary ones. Additionally, a prospective cohort study in Sweden found no difference in anxiety levels among participants who had a rectal resection, abdominoperineal resection, or colonic resection, although those who underwent colonic resection reported less anxiety at discharge than before surgery [36]. Anxiety due to ostomy-related issues was frequently reported, particularly in qualitative studies [15, 16, 44]. Participants voiced worries about potential or existing ostomy complications such as leakage, noise, odor, or hernias during interviews. These issues presented daily challenges, impeding their ability to resume normal activities [15, 16, 44].

Several studies have examined the role of cancer treatment side effects and complications on anxiety levels. These studies found that participants who reported complications after CRC surgery experienced greater anxiety than those without complications [26, 33, 46]. Chemotherapy-Induced Peripheral Neuropathy (CIPN) is one of the most studied CRC treatment side effects. Participants with more severe CIPN also reported higher anxiety levels [24, 38, 50].

Consequences of anxiety in CRC survivors

Global health status / quality of life

In multiple studies, it has been observed that a heightened level of anxiety is closely associated with poor global health status and reduced quality of life [6, 18, 30, 45, 54]. However, Gonzalez-Saenz de Tejada et al. [27] found no significant correlation between these variables in their longitudinal study in Spain.

Functioning

A cross-sectional study of 175 CRC survivors with ostomies in China discovered an association between higher anxiety scores and increased supportive care needs, such as physiology and daily living needs, psychological needs, and health information needs [59]. Although this study did not find a connection between anxiety and sexual needs, another cross-sectional study in Turkey and a qualitative study in the UK identified a link between anxiety and sexual functioning among CRC survivors [16, 18]. Furthermore, qualitative studies disclosed that participants' social or emotional functioning was negatively impacted due to their ostomy [15, 16]. During these interviews, participants mentioned limiting their food or drink intake before social activities due to worries about handling ostomy-related issues in public spaces.

A retrospective longitudinal study conducted in China found that participants with elevated anxiety levels were less likely to start adjuvant chemotherapy early (within 4 weeks after operations) [62]. In another prospective cohort study in the US involving healthcare providers diagnosed with CRC, it was discovered that individuals with anxiety often led unhealthy lifestyles, such as consuming alcohol or smoking [55]. Moreover, participants with high anxiety engaged in less physical activity [57]. A longitudinal study in China on 67 rectal cancer survivors undergoing colostomy surgery found that higher levels of anxiety significantly predict lower psychosocial behavioral responses in colostomy patients [37].

Symptoms/ problems

While Akyol et al. [18] found no connection between anxiety and insomnia, other studies have identified a significant association [35, 53]. For instance, Hyphantis et al. [35] found that CRC patients with increased anxiety after one year had more difficulty falling asleep, but there was no significant change in waking up early.

Instruments used to assess anxiety

In the included studies, researchers used a variety of instruments to measure the participants' anxiety levels. The most frequently used instrument was the Hospital Anxiety and Depression Scale (HADS) [66], a self-reported tool that allows participants to assess their own anxiety and depression levels. In contrast, some studies used International Classification of Diseases (ICD) codes [67], which reflect anxiety disorders officially diagnosed by mental health specialists. Further information about each instrument is summarized in Table 3. Cutoff points used to determine the presence or severity of anxiety in included studies are summarized in Table 1. In each of the three review manuscripts, we only counted the usage of individual tools once, regardless of how often they appeared. This method was used to avoid multiple counts, particularly if the original studies from our research were also included in those review manuscripts.

Table 3 Anxiety measurement tools
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Discussion

This scoping review illustrates the unique anxiety-related factors that specifically affect the CRC population, a perspective not commonly found in reviews focusing on the general cancer population. A recurring theme among included studies is the presence of anxiety associated with bowel or ostomy dysfunctions, common side effects of CRC treatments. Qualitative studies focusing on CRC survivors, particularly those with ostomies, consistently find that individuals frequently dealing with embarrassing situations due to ostomy complications exhibit increased anxiety [15, 16, 44]. These situations commonly stem from ostomy leakage, odor, or noise in public spaces, contributing to heightened anxiety about social participation. To cope, these individuals often restrict their food and drink intake before or during social events, or continually look for restroom facilities when out [15, 16]. This hyper-vigilance and resulting self-imposed dietary limitations contribute to their high anxiety levels. Ultimately, such anxiety can lead to social withdrawal, creating a vicious cycle that further intensifies anxiety [15, 20]. These findings align with studies conducted on individuals who have undergone ostomy surgery for various reasons, indicating a broad impact of this condition on mental health [78,79,80].

Our findings show that high levels of proinflammatory cytokines (IL-1, IL-6, IL-8, TNF-α), low levels of IL-10 [41, 43], and high fractalkine levels (defined as levels > 3mg/L) [42] are linked to increased anxiety in CRC patients. These findings support previous studies on neuroimmune interaction in the context of cancer [81,82,83]. Stress, tumor biology, and cancer treatments affect neurobiology through inflammation, influencing anxiety symptoms in cancer patients by linking sympathetic nerve activity and immune responses to tumor development [81, 82]. Further, anxiety can present as physical symptoms such as pain and fatigue [47] through these neuroimmune mechanisms, threatening the long-term health and physical functioning of CRC patients. Understanding these interactions would provide a more comprehensive view of the relationship between psychological and biological health in this population.

The HADS is a commonly used self-report questionnaire for measuring anxiety and depression in oncology and other health settings. This questionnaire was also predominantly used in our reviewed studies with the CRC population (see Table 3). However, as shown in Table 1, we observed that different articles used various cut-off points. While most studies dichotomized the subjects using a score of 8, Zhang et al. and Zhu et al. [60, 62] used a score of 11, and Song et al. [51] used 9. This variation in cut-off points could potentially lead to contrasting results when comparing the anxiety rate between different groups, as opposed to conducting a correlation analysis.

Anxiety, as determined by ICD codes, and as referenced in several studies [6, 8, 32, 40], could potentially lead to inconsistencies when comparing with other studies that utilize self-report questionnaires. The ICD codes are used to indicate that an individual has been clinically diagnosed with an anxiety disorder by a healthcare professional. This is in contrast to self-reported surveys where individuals themselves report their symptoms and experiences, which may or may not align with a clinical diagnosis.

In quantitative studies, excluding those with pre-existing clinical anxiety before a CRC diagnosis or conducting a longitudinal study that compares anxiety levels at different times can help determine whether the observed anxiety is directly related to the CRC diagnosis or its treatment. Understanding this is crucial. If anxiety is a by-product of CRC or its treatment, it can inform more targeted prevention interventions for this population. However, some cross-sectional studies we reviewed did not exclude pre-existing clinical anxiety cases before the CRC diagnosis [18,19,20,21,22,23,24,25, 29, 30, 38, 47, 50, 51, 56], making it difficult to pinpoint the root source of the anxiety. This lack of clarity could potentially skew the results and interpretations.

In line with previous review studies of CRC survivors [6, 8], this scoping review presents mixed results about the association between age and anxiety levels. This could be due to differences in study populations, designs, measurement tools, and analysis methods. Boehmer, Clark, et al. [22] and Boehmer, Ozonoff, et al. [23] examined anxiety and health-related anxiety levels across different age groups at diagnosis. In their study of sexual minority CRC survivors [22], they found higher anxiety levels and a greater likelihood of health-related anxiety in those diagnosed between 21–49 years, compared to those diagnosed at 65 years and older. However, the 50–64 years age group showed no significant differences in anxiety level or health-related anxiety compared to the oldest age group. In a separate study involving both heterosexual and sexual minority CRC survivors, Boehmer, Ozonoff, et al. [23] found that younger individuals, specifically those in the 21–49 year age group, were more likely to experience health-related anxiety, as assessed by the single item QLQ-CR29, compared to those aged 65 years and older. However, the association between age and anxiety, as assessed by the HADS, was statistically non-significant in this group. This discrepancy could be due to the different aspects of anxiety each tool measures. On the other hand, Howren et al. [32] categorized participants into three groups: young-onset CRC (diagnosed before 50 years old), average-age-onset CRC (diagnosed at 50 years or older), and cancer-free controls. They found that participants diagnosed with CRC under the age of 50 had a similar risk of anxiety to cancer-free controls in the same age group. However, those diagnosed with CRC after the age of 50 had a higher risk of anxiety than cancer-free individuals in the same age group. After adjusting for confounding effects such as current age, the differences in anxiety risk between CRC survivors diagnosed before 50 years and those diagnosed at or after 50 years were found to be statistically insignificant [32]. Unlike these studies [22, 23, 32], other included studies [28, 30, 33, 45, 54] utilized participants' current age at the time of the study to examine its association with anxiety levels. Some of these studies [30, 33, 54] found no significant link between age and anxiety levels, while others [45, 65] found an association. Hess et al. [30] only included CRC survivors who were 60 years or older (median age = 68), which might have led to insignificant differences in anxiety levels across different ages. Hu et al. [33] and Tamura [54] compared anxiety levels between those < 65 and ≥ 65, finding no significant differences in anxiety levels between the two age groups. However, Gonzalez-Saenz de Tejada et al. [65] found that older CRC survivors reported a more significant decrease in anxiety levels after a year of surgery. Mols et al. [45] discovered that older participants reported lower anxiety levels, aligning with findings from studies of the general cancer population [14, 84].

Limitations

While this review is intended to be comprehensive, it does have limitations that are largely consistent with those of a scoping review design. We used study design, timelines, mechanistic plausibility, and interpretation to categorize variables as risk factors or consequences of anxiety. However, the observational nature of most studies, along with some cross-sectional designs, limits our ability to establish cause-and-effect relationships between anxiety and other variables definitively. Consequently, some variables were classified as risk factors in some studies and as consequences of anxiety in others. In addition, our scoping review identifies and maps factors associated with anxiety in CRC patients, but it does not provide an in-depth analysis of study quality and risk of bias, as systematic reviews typically do. Instead, it offers a broad overview of existing literature, identifying research trends, gaps, and future investigation areas. As an exploratory study, this scoping review may lack the rigor of systematic reviews due to its less strict inclusion criteria. However, this approach allows for a more inclusive and extensive literature examination, capturing a broader range of studies and perspectives. Furthermore, anxiety is a multidimensional concept that shares common characteristics with other emotional states like depression. In the context of cancer, anxiety is particularly linked to the fear of cancer recurrence and the fear of death, making it hard to distinguish from other emotional conditions. This complexity is a significant limitation of our study and should be considered when interpreting the results.

Recommendations for future research

It is crucial to identify modifiable factors related to anxiety, as these factors could be the focus of future research on targeted prevention methods. Furthermore, understanding the complex relationships between these factors can provide a holistic view, enabling the implementation of early prevention strategies. While many qualitative studies have pinpointed psychosocial issues related to ostomy complications in the CRC population, few quantitative studies have investigated this. Benedict et al. [20] found a link between diarrhea and anxiety in survivors of rectal or anal cancer after treatment. However, it was not distinguished whether these individuals had an ostomy or not. In people with ostomies, diarrhea does not necessarily lead to ostomy leakage. Therefore, for future studies, we recommend using ostomy-specific questionnaires in quantitative research of CRC-related psychosocial outcomes. This will help investigate the correlation between ostomy complications and psychosocial problems among CRC survivors with ostomies.

Conclusions

As the survival rates for CRC increase, understanding the potential biological and psychosocial effects of CRC and its treatments becomes increasingly critical. Our review significantly contributes to this understanding by identifying various predictors and outcomes of anxiety in this group. Modifiable factors present targets for interventions aimed at reducing anxiety and enhancing quality of life. Non-modifiable risk factors help pinpoint patients at high risk for early psychological support. Moreover, these risk factors can be further examined to comprehend their interactions.