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1Department of Obstetrics and Gynecology, Chongqing Key Laboratory of Maternal and Fetal Medicine/Joint International Research Laboratory of Reproduction & Development, Ministry of Education/The Innovation and Talent Recruitment Base of Maternal-Fetal Medicine, The First Affiliated Hospital of Chongqing Medical University, 400042 Chongqing, China
2Nursing Department, The First Affiliated Hospital of Chongqing Medical University, 400042 Chongqing, China
*Corresponding Author(s):dingjinhua@zyyy2.wecom.work (Jinhua Ding)
| History | Submitted: 12 August 2023 | Accepted: 22 September 2023 | Published: 15 August 2025 |
| Copyright: | ©2025 The Author(s). Published by MRE Press. |
Background: Patients with cervical cancer (CC) have heavy physical and mental burden and have been found to have worse quality of life (QoL). Supportive care for patients with CC is usually completed by general nurses during hospitalization and provides only basic psychological comfort, which is not satisfactory. Methods: Women diagnosed with cervical cancer who were about to undergo surgery were randomly assigned to the control or intervention groups. The control group received routine health education and psychological nursing measures, while the intervention group received a psychoeducational intervention program. The psychoeducational intervention program included a five-session, 24-week full-course group psychoeducational therapy and WeChat instruction. Patients with cervical cancer were assessed with standardized questionnaires, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), Cervical Cancer Module (EORTC QLQ-CX24), Chinese version of Mishel’s Uncertainty in Illness Scale (C-MUIS), and Chinese version of the Medical Outcomes Study Social Support Survey (MOS-SSS-CM). All data were collected at baseline and post-intervention. Results: Patients who received the psychoeducational intervention program reported better physical functioning (p < 0.001), social functioning (p = 0.016) and global health status (p = 0.018), and they felt a lower financial burden (p < 0.001), as measured by the EORTC QLQ-C30. They felt better about their body image (p = 0.030) and had fewer lymphedema and other symptoms (p = 0.024) (p = 0.001) on the EORTC QLQ-CX24. They reported significantly greater reductions in the ambiguity, inconsistency and unpredictability subscales and overall illness uncertainty than the control group, as measured by the C-MUIS (p < 0.005). They perceived better tangible support, affectionate support and positive social interaction as measured by the MOS-SSS-CM (p < 0.005). Conclusions: The psychoeducational intervention program is feasible with potentially benefiting effects for patients with cervical cancer. Multicenter studies with larger sample sizes and longer follow-up periods are warranted to confirm the results. Clinical Trial Registration: ChiCTR2500106354.
Cite this article
Ying Jiang, Jinhua Ding, Juan Li, Shujun Wang, Jinfeng Wang, Juju Chen. A psychoeducational intervention program for cervical cancer: a randomized controlled trial.European Journal of Gynaecological Oncology,2025,46(8):58-67 DOI:10.22514/ejgo.2025.109
1. Introduction
Cervical cancer (CC) is the most common malignancy of the female reproductive tract and ranks fourth in both incidence and mortality among female malignancies [1, 2]. Every year, 604,127 women are diagnosed, and 341,831 die from the disease worldwide [2]. Statistics from the National Cancer Centre in China show that there were 119,300 new cases of CC in 2016, 37,200 women died of CC this year, and the incidence and mortality of CC are increasing yearly [3]. CC is an important disease that endangers women’s health and life in China.
Radical hysterectomy (RH) with bilateral pelvic lymphadenectomy is the first choice for the treatment of early CC [4]. However, this operation is extensive and traumatic, the incidence of complications, such as urinary retention, anxiety, depression and sexual dysfunction, is high, and the patient will lose fertility functions [5]. Therefore, concerns about the prognosis of cancer, the physical and mental pain and the economic burden brought by treatment have a great impact on the physical and mental health and quality of life (QoL) of patients. Furthermore, patients with CC have been found to have worse QoL scores, not only when compared to the general population but also when compared with other gynecological cancer survivors [6]. In China, supportive care for patients with CC is usually completed by general nurses during hospitalization and provides only basic psychological comfort. Supportive care for patients with CC has not been satisfactory [7, 8].
Psychoeducational interventions (PEIs) provide patients and their families with adequate and realistic knowledge concerning the disease, related treatments, collateral effects, possible complications and solutions for practical problems [9, 10]. The PEIs address the affective and cognitive elaboration of experiences related to the illness, the psychological and social process of adaptation to cancer, awareness of oneself and one’s own needs, mood improvement, stress management, problem solving and coping strategies [11]. Moreover, working as a team allows patients to achieve a greater sense of autonomy, to be less dependent on medical staff, to use adaptive problem-solving strategies and to develop new social ties. Patients may perceive their illness positively due to the feelings of relief and protection provided by the group [12, 13]. Group forms of PEI have achieved good results in patients with breast cancer and other patients, and studies of patients with gynecological cancer have elicited more attention in the field of cancer care rehabilitation in recent decades [14, 15]. However, in China, group forms of PEI are rarely used for patients with cancer, and there is no PEI-related research applicable to patients with cervical cancer.
Chinese women are generally not good at expressing their true thoughts after suffering from malignant tumors, especially CC, which involves sexual life and reproductive functions. Furthermore, routine follow-up programs have failed to provide patients with effective ways to solve the problem. Based on the group forms of PEI programs for patients with other malignant tumors, this study explored specific forms and protocols of group forms of PEI suitable for CC patients in mainland China to better meet the supportive needs of CC patients and promote their physical and mental rehabilitation.
2. Methods
2.1 Study design and participants
The study was conducted in a third-grade hospital in Chongqing. Newly diagnosed patients with CC scheduled for surgery from April 2022 to June 2022 were randomized using a random number generator to either the control group or the intervention group. To reduce the quality of life of elderly patients, which does not have a high impact on the results of this study, patients with a new diagnosis of stage IA1–stage II A2 cervical infiltrating carcinoma with planned RH who were no older than age 65 and consented to participate were recruited for the study. Patients suffering from serious physical diseases of the heart, liver or kidney and those with a history of mental illness or central nervous system diseases, mental impairment, hearing impairment or communication difficulties, significant life events that caused emotional changes within the last six months, and drug or alcohol dependence were excluded. The proportion of patients enrolled in the intervention group and the control group was 1:1. Patients in the intervention group formed a treatment team every 4–6 patients according to the order of inclusion.
2.2 Intervention
Patients in the control group were given routine health education and psychological nursing by the responsible nurse according to the treatment process during their stay in the hospital and were followed up by telephone one week after discharge.
In the intervention group, the intervention plan based on the group form of PEI combined with mindfulness techniques, relaxation and music therapy was added to routine care. The focus of the psychoeducational intervention was to provide informative, emotional and relational support to the participants during the treatment. The program consisted of five sessions that were delivered before or after the commencement of cancer treatment. The specific time was on preoperative day 1 or 2 and at 1, 4, 12 and 24 weeks after surgery on an individual basis. The second time, the research nurses conducted the program with each patient individually before the patients left the hospital, and the remaining sessions were conducted as a group. The first and fifth group activities were held in the classroom of the department and were conducted face to face by the research nurses and patients enrolled in each group. Due to COVID-19, the third and fourth group activities were conducted in the form of a WeChat group video chat. Each session lasted approximately 90 minutes, except for the second session. In the process of rehabilitation, patients in the intervention group could ask questions on WeChat at any time, and the study nurse replied as soon as possible at her convenience; other patients could also share their experience. The schedule and details of the intervention program are listed in Table 1.
| Session | Process and content |
| 1st session (1 or 2 days preop) Group format (90 min) | 1. The study nurses introduced tips about keeping secrets, being frank and sincere, and turning off the phone during activities 2. The study nurse and the group members introduced themselves 3. The study nurses introduced the following questions: What is cervical cancer? What are the risk factors, clinical manifestations, diagnosis and main treatment of cervical cancer? 4. Common side effects of treatments such as surgery (e.g., effects on body image and sex life) 5. Patients share their psychological feelings and confusion after the illness 6. Patients share ways to cope with confusion and encourage each other 7. The study nurses guide patients in relaxation techniques and end activities with relaxing music |
| 2nd session (1 week post-op) Individual format (30 min) | 1. Postoperative wound management 2. Postoperative dietary plan 3. Postoperative activity and rehabilitation exercise method 4. Observation points and precautions about postoperative complications 5. Follow-up time and procedure |
| 3rd session (4 weeks post-op) Group format (90 min) | 1. Patients discuss their problems and share coping strategies 2. Research nurses answer professional questions 3. Study nurses end activities with relaxing music |
| 4th session (12 weeks post-op) Group format (90 min) | 1. Patients share their recovery after surgery 2. Sexuality 3. Communication skills with family and friends 4. Social role changes 5. Study nurses end activities with relaxing music |
| 5th session (24 weeks post-op) Group format (90 min) | 1. Patients share their recovery after surgery 2. Patients share their social role adaptation 3. Study nurses thank the patients for their full participation in the program and conclude with music |
2.3 Quality control
The interventions were conducted in collaboration with project members. The major nurse researcher was a registered nurse and master’s student with 13 years of gynecological clinical work experience who had participated in teaching for 10 years and had good scientific research ability. To better implement this project, she learned basic psychological nursing skills and group psychoeducational skills. First, the research nurse introduced the purpose, form, main content and topics of the program. Participants were required to silence their mobile phones during the activity and not leave during the event unless there were special circumstances. The patients were fully informed and signed informed consent before entering the activity process. The questionnaire was distributed by the researchers and explained to the patients during completion.
2.4 Outcome measures
Sociodemographic and clinical characteristics were gathered during recruitment. Baseline survey data for both groups were measured by the questionnaire before the intervention was initiated and were reassessed postoperatively 24 weeks after surgery. Well-validated quantitative outcome measures were utilized to assess quality of life, uncertainty and social support.
QoL was assessed using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the Cervical Cancer module (EORTC QLQ-CX24).
The EORTC QLQ-C30 is the European Centre for Cancer Research’s core scale for all cancer patients. It is a 30-item, cancer-specific questionnaire for the assessment of five functioning scales, three symptom scales, a scale for global health status and overall QoL, and six single items [16]. Items 29 and 30 are evenly divided into 7 grades with 1–7 points from very bad to very good. The remaining items are evenly divided into 4 grades, none, a little, more and very much, with 1–4 points, respectively. In the functional and global health scales, higher scores indicate better functioning or status, while higher scores on the symptom scales and for the single items reflect more problematic symptoms [17, 18].
The European Centre for Cancer Research Quality of Life Cervical Cancer (EORTC QLQ-CX24) questionnaire is a validated disease-specific and treatment-specific questionnaire that mainly studies the quality of life and sexual life of patients with cervical cancer after treatment [19]. The EORTC QLQ-CX24 is a 24-item, cervical cancer-specific questionnaire composed of three multi-item scales and six single-item scales. The items are evenly divided into 4 grades: none, a little, more and very much, with 1–4 points, respectively. In sexual activity and sexual enjoyment, higher scores indicate better functioning; however, in the other scales and single items, higher scores reflect more problematic functioning or status [20].
Perceived uncertainty among the patients was measured by the Chinese version of Mishel’s Uncertainty in Illness Scale (C-MUIS). The C-MUIS consists of 33 items scored on a 5-point Likert scale divided into four subscales: ambiguity, complexity, inconsistency and unpredictability. Higher scores indicate higher levels of uncertainty: 32.0~74.7 is classified as a low level, 74.8~117.4 as a medium level, and 117.5~160.0 as a high level [21, 22].
The Chinese version of the Medical Outcomes Study Social Support Survey (MOS-SSS-C) was used to measure perceived social support [23]. The MOS-SSS-C is a 20-item questionnaire. There are 19 items with a 5-point Likert scale representing four dimensions of social support in four subscales, including tangible support, affectionate support, positive social interaction and emotional-informational support. The remaining item assesses the size of the social network of close relatives and friends. Four subscale scores and the overall support index can be calculated, with higher scores indicating more availability of social support [24].
2.5 Data analysis
Statistical analysis was performed using the statistical software SPSS 21.0 software (SPSS software, Palo Alto, CA, USA). Data were first carefully examined to identify missing data and any outliers. When the data were normal and the variance was uniform, t-test was used, and the mean ± standard deviation (SD) deviation was used for statistical description. When the data were skewed or unequal in variance, the Wilcoxon rank-sum test was used, and the median and qrange were used for statistical analysis, which was expressed as M (P25, P75). Count data were described statistically using frequency (%), and comparisons between groups were performed using Fisher’s exact test or chi-square test according to the data distribution. When p < 0.05, the difference was considered statistically significant. All statistical tests were two-sided, and the level of significance was set at 0.05.
3. Results
3.1 Participants’ recruitment flow and compliance
During the study period, 63 patients with cervical cancer who were admitted to the hospital were successfully recruited based on the inclusion and exclusion criteria, patients’ wishes and time conflicts (intervention group = 31, control group = 32). Fig. 1 shows the details of recruitment and the flow of participants through the study. All participants in the intervention group and the control group completed the baseline assessments. Attrition for the intervention group from baseline to completion of the intervention was 3.23% (n = 1). Attrition for the control group from baseline to completion was 6.25% (n = 2). Ninety-seven percent of the intervention group participants attended 5 classes. Only one patient in the intervention group did not participate in all the treatments because she was injured due to a fracture and was unable to participate. Two participants in the control group failed to complete the final investigation because they did not return to the hospital on time for re-examination.
Fig. 1.Recruitment of participants.
3.2 Participant characteristics
The demographic and clinical characteristics, including age, marital status, education, profession, family income, medical insurance, complication, pathological type, stage of cancer, radiotherapy and chemotherapy, were not significantly different between the intervention group and the control group. Specific data are shown in Table 2. Regarding the age of the two groups (median 45.3 vs. 48.7; p = 0.156), most of the participants were in their mid-40 s. The majority of them were married, approximately half of them had a household income of less than 5000 RMB a month, and the reimbursement ratio of their medical insurance was low. There were 5 patients in the control group and 5 patients in the intervention group with single complications (i.e., well-controlled hypertension and hyperthyroidism, hepatitis B, chronic enteritis, renal cyst and mild anemia). The predominant pathological type was squamous cell carcinoma. First-stage patients accounted for 56.7%, and the vast majority of patients received postoperative radiotherapy and chemotherapy (90%).
| Characteristics | Control group (n = 30) | Intervention group (n = 30) | Chi-square value | p value | |
| Age (mean ± SD) | 45.37 ± 8.156 | 48.70 ± 9.742 | 0.156‡ | ||
| Marital status | |||||
| Married | 28 (51.85) | 26 (48.15) | 0.671‡ | ||
| Unmarried | 2 (33.33) | 4 (66.67) | |||
| Education | |||||
| No formal education | 3 (75) | 1 (25) | 0.062‡ | ||
| Grade school | 8 (53.33) | 7 (46.67) | |||
| High school | 11 (35.48) | 20 (64.52) | |||
| College and more | 8 (80) | 2 (20) | |||
| Profession | |||||
| Freelance work | 7 (50) | 7 (50) | 0.218‡ | ||
| Employee | 4 (57.14) | 3 (42.86) | |||
| Farmer | 4 (30.77) | 9 (69.23) | |||
| Retired | 2 (28.57) | 5 (71.43) | |||
| Others | 13 (68.42) | 6 (31.58) | |||
| Family income (RMB/mon) | |||||
| <5000 | 17 (48.57) | 18 (51.43) | 0.369‡ | ||
| 5000–10,000 | 11 (61.11) | 7 (38.89) | |||
| >10,000 | 2 (28.57) | 5 (71.43) | |||
| Medical insurance | |||||
| Low reimbursement ratio | 17 (47.22) | 19 (52.78) | 0.278 | 0.598† | |
| High reimbursement ratio | 13 (54.17) | 11 (45.83) | |||
| Complication | |||||
| Yes | 5 (16.67) | 5 (16.67) | 0.000 | 1.000† | |
| No | 25 (83.33) | 25 (83.33) | |||
| Pathological type | |||||
| Squamous cell carcinoma | 22 (45.83) | 26 (54.17) | 0.344‡ | ||
| Adenomatous carcinoma | 4 (50) | 4 (50) | |||
| Adenosquamous carcinoma | 2 (100) | 0 (0) | |||
| Others | 2 (100) | 0 (0) | |||
| Stage of cancer | |||||
| Stage I | 17 (50) | 17 (50) | 0.000 | 1.000† | |
| Stage II | 13 (50) | 13 (50) | |||
| Radiotherapy and chemotherapy | |||||
| Yes | 27 (50) | 27 (50) | 1.000‡ | ||
| No | 3 (50) | 3 (50) | |||
| SD: standard deviation; †Chi-square test; ‡Fisher’s exact probability method. |
3.3 Outcomes
The comparison of the outcome measures of the two groups is shown in Table 3. There were no significant baseline differences between the two groups on the EORTC QLQ-C30. After the intervention program, physical functioning (median, 100 vs. 90; p < 0.001), social functioning (median, 100 vs. 83.33; p = 0.016) and global health status (median, 29.17 vs. 16.67; p = 0.018) were significantly different between the two groups. The intervention group was better than the control group, while the control group felt a greater financial burden (median 0 vs. 33.33; p < 0.001).
| Domain | Preintervention | Post-intervention | |||||||
| Control group | Intervention group | Z | p value | Control group | Intervention group | Z | p value | ||
| EORTC QLQ-C30 | |||||||||
| Physical functioning | 96.67 (93.33, 100.00) | 100.00 (86.67, 100.00) | −0.025 | 0.980 | 90.00 (86.67, 100.00) | 100.00 (93.33, 100.00) | −3.611 | <0.001 | |
| Role functioning | 100.00 (83.33, 100.00) | 100.00 (100.00, 100.00) | −0.486 | 0.627 | 100.00 (83.33, 100.00) | 100.00 (83.33, 100.00) | −0.217 | 0.828 | |
| Emotional functioning | 83.33 (75.00, 100.00) | 91.67 (66.67, 100.00) | −0.091 | 0.928 | 95.83 (83.33, 100.00) | 100.00 (91.67, 100.00) | −0.791 | 0.429 | |
| Cognitive functioning | 83.33 (66.67, 100.00) | 100.00 (83.33, 100.00) | −1.135 | 0.256 | 83.33 (66.67, 100.00) | 83.33 (83.33, 83.33) | −0.264 | 0.792 | |
| Social functioning | 83.33 (66.67, 100.00) | 83.33 (66.67, 100.00) | −0.553 | 0.580 | 83.33 (66.67, 100.00) | 100.00 (83.33, 100.00) | −2.412 | 0.016 | |
| Fatigue | 0 (0, 11.11) | 0 (0, 22.22) | −0.888 | 0.375 | 11.11 (0, 22.22) | 11.11 (0, 22.22) | −0.877 | 0.381 | |
| Nausea and vomiting | 0 (0, 0) | 0 (0, 0) | −0.909 | 0.363 | 0 (0, 0) | 0 (0, 0) | −0.463 | 0.644 | |
| Pain | 0 (0, 0) | 0 (0, 0) | −0.500 | 0.617 | 0 (0, 16.67) | 0 (0, 0) | −1.332 | 0.183 | |
| Dyspnea | 0 (0, 0) | 0 (0, 0) | −1.506 | 0.132 | 0 (0, 33.33) | 0 (0, 0) | −1.280 | 0.200 | |
| Insomnia | 16.67 (0, 33.33) | 0 (0, 33.33) | −1.296 | 0.195 | 16.67 (0, 33.33) | 0 (0, 33.33) | −1.252 | 0.210 | |
| Appetite loss | 0 (0, 33.33) | 0 (0, 0) | −1.043 | 0.297 | 0 (0, 0) | 0 (0, 0) | −0.406 | 0.685 | |
| Constipation | 0 (0, 33.33) | 0 (0, 0) | −1.654 | 0.098 | 0 (0, 33.33) | 0 (0, 0) | −1.824 | 0.068 | |
| Diarrhea | 0 (0, 0) | 0 (0, 0) | −1.762 | 0.078 | 0 (0, 0) | 0 (0, 0) | −0.034 | 0.973 | |
| Financial difficulties | 33.33 (33.33, 66.67) | 33.33 (0, 33.33) | −1.806 | 0.071 | 33.33 (33.33, 66.67) | 0 (0, 33.33) | −3.658 | <0.001 | |
| Global health status | 50.00 (25.00, 50.00) | 33.33 (16.67, 50.00) | −1.838 | 0.066 | 16.67 (16.67, 16.67) | 29.17 (16.67, 50.00) | −2.365 | 0.018 | |
| EORTC QLQ-CX24 | |||||||||
| Body image | 16.67 (11.11, 44.44) | 0 (0, 11.11) | −3.046 | 0.002 | 11.11 (0, 33.33) | 0 (0, 11.11) | −2.165 | 0.030 | |
| Symptom experience | 3.03 (3.03, 6.06) | 4.55 (0, 9.09) | −0.766 | 0.444 | 6.06 (3.03, 12.12) | 3.03 (0, 3.03) | −3.179 | 0.001 | |
| Lymphedema | 0 (0, 0) | 0 (0, 0) | −1.426 | 0.154 | 0 (0, 33.33) | 0 (0, 0) | −2.256 | 0.024 | |
| Peripheral neuropathy | 0 (0, 0) | 0 (0, 33.33) | −4.219 | <0.001 | 0 (0, 33.33) | 16.67 (0, 33.33) | −0.125 | 0.900 | |
| Menopausal symptoms | 0 (0, 0) | 0 (0, 0) | −1.404 | 0.160 | 0 (0, 0) | 0 (0, 0) | 0.000 | 1.000 | |
| Sexual activity | 0 (0, 0) | 0 (0, 0) | −0.101 | 0.919 | 0 (0, 0) | 0 (0, 0) | −1.079 | 0.281 | |
| Sexual enjoyment | 100.00 (66.67, 100.00) | 100.00 (100.00, 100.00) | −1.847 | 0.065 | 66.67 (66.67, 83.33) | 100.00 (66.67, 100.00) | −1.021 | 0.307 | |
| Sexual/Vaginal functioning | 8.33 (0, 16.67) | 0 (0, 0) | −2.440 | 0.015 | 16.67 (8.33, 25.00) | 16.67 (0, 16.67) | −0.592 | 0.554 | |
| Sexual worry | 50.00 (33.33, 66.67) | 0 (0, 0) | −4.238 | <0.001 | 33.33 (0, 66.67) | 33.33 (0, 33.33) | −0.457 | 0.648 | |
| C-MUIS | |||||||||
| Ambiguity subscale | 45.05 ± 2.35 | 45.05 ± 2.11 | 3.511 | 0.998 | 44.43 ± 2.91 | 39.30 ± 6.29 | −4.059 | <0.001 | |
| Complexity subscale | 26.00 (24.00, 28.00) | 25.00 (24.00, 28.00) | −0.261 | 0.794 | 26.00 (24.00, 26.00) | 26.00 (24.00, 28.00) | −0.435 | 0.663 | |
| Inconsistency subscale | 25.42 ± 1.54 | 24.90 ± 1.36 | 2.284 | 0.050 | 26.00 (26.00, 28.00) | 21.00 (19.00, 25.00) | −4.412 | <0.001 | |
| Unpredictability subscale | 14.00 (14.00, 14.00) | 14.00 (13.00, 15.00) | −1.099 | 0.272 | 15.00 (14.00, 16.00) | 14.00 (13.00, 15.00) | −2.178 | 0.029 | |
| Total score | 112.52 ± 3.08 | 102.85 ± 3.07 | −4.45 | 0.559 | 108.5 (106.00, 113.00) | 100.00 (97.00, 108.00) | −3.131 | 0.002 | |
| MOS-SSS-C | |||||||||
| Social network | 3.50 (2.00, 5.00) | 3.00 (3.00, 5.00) | −0.205 | 0.837 | 3.50 (2.00, 5.00) | 3.00 (2.00, 4.00) | −1.187 | 0.235 | |
| Tangible support | 16.00 (14.00, 19.00) | 18.00 (16.00, 20.00) | −1.842 | 0.065 | 16.00 (12.00, 19.00) | 18.00 (16.00, 20.00) | −2.555 | 0.011 | |
| Emotional-informational support | 31.00 (24.00, 37.00) | 32.00 (24.00, 40.00) | −1.059 | 0.290 | 29.00 (23.00, 37.00) | 32.00 (27.00, 40.00) | −1.235 | 0.217 | |
| Affectionate support | 12.00 (10.00, 15.00) | 13.50 (12.00, 15.00) | −1.126 | 0.260 | 12.00 (10.00, 15.00) | 14.50 (12.00, 15.00) | −2.305 | 0.021 | |
| Positive social interaction | 16.00 (14.00, 20.00) | 17.00 (13.00, 20.00) | −0.415 | 0.678 | 16.00 (13.00, 20.00) | 17.50 (16.00, 20.00) | −2.046 | 0.041 | |
| EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; EORTC QLQ-CX24: European Centre for Cancer Research Quality of Life Cervical Cancer; C-MUIS: Chinese version of Mishel’s Uncertainty in Illness Scale; MOS-SSS-C: Chinese version of the Medical Outcomes Study Social Support Survey. |
Both before and after intervention, the body image of the intervention group was better than that of the control group on the EORTC QLQ-CX24. Similar to the EORTC QLQ-C30, lymphedema and other symptom experiences (median 6.06 vs. 3.03; p = 0.001) were significantly different, and symptoms were more pronounced in the control group. Before the intervention, the control group had worse sexual/vaginal functioning and more significant sexual concerns than the intervention group. However, there was no significant difference in sexual/vaginal functioning or sexual concerns between the two groups after the intervention program.
There were no significant differences in the total score or dimensions of disease uncertainty between the two groups before intervention. After intervention, the total scores of disease uncertainty in the intervention group and the control group were median 100 vs. 108; p = 0.002. The patients in the control group reported greater uncertainty about their disease. In the three dimensions of the ambiguity subscale (median 39.3 vs. 44.43; p < 0.001), inconsistency subscale (median 21 vs. 26; p < 0.001) and unpredictability subscale (median 14 vs. 15; p = 0.029), the scores of the intervention group were lower than those of the control group.
In the MOS-SSS-C, the intervention group demonstrated a statistically significant improvement in the subscales of tangible support (median 18 vs. 16; p = 0.011), affectionate support (median 14.5 vs. 12; p = 0.021) and positive social interaction (median 17.5 vs. 16; p = 0.041). Patients who experienced the group form of PEI perceived better social support.
4. Discussion
Different from previous psychological intervention studies on gynecological cancer patients, this study only included CC patients. Patients with the same disease can arouse more resonance in the process of participation. In the intervention group of this study, only one patient was unable to participate in the follow-up treatment due to trauma. Patients are generally willing to participate in the activity, actively participate, ask questions and express concerns, and the overall acceptance is very high. Members of the group became acquainted with each other during the first activity and then went through surgery and other treatments together. Throughout the treatment cycle, they expressed their concerns, exchanged experiences, encouraged and blessed each other, and became good comrades in arms to overcome the disease together. Due to the COVID-19 pandemic, some activities were changed from on-site activities to WeChat groups. The WeChat group allowed the participants to ask questions at any time during the rehabilitation process that were answered by the study nurses. Communication between patients and medical staff and between patients could be performed at any time, which provided convenience for patients and allowed for timely solutions to their problems. Patients and medical staff accepted and adapted to this form, and consistent with Gitonga et al.’s [25] study, cancer patients were able to receive web-based interventions [25]. CC patients in the intervention group were very receptive to the group forms of PEI in the form of on-site and WeChat activities during the treatment and recovery period after diagnosis, which can be tried in hospitals with many patients with CC.
In the first group activity, the researchers explained to the patients the causes of cervical cancer, clinical manifestations, main treatment methods, prognosis and other disease-related knowledge so that the patients could obtain a comprehensive and systematic understanding of the disease and could be psychologically prepared from the beginning to better accept and cope with it. In the subsequent group activities, the researchers provided corresponding professional guidance according to each treatment stage and treatment situation of the patients. Targeted guidance was given to patients with special problems so that they could master the correct coordination methods to better implement rehabilitation measures and promote rehabilitation. Patients who receive PEI have better physical function recovery and overall health status [26]. The group form of PEI in this study can promote the physical and mental rehabilitation of patients with CC.
CC treatment reduces the sexual function of patients due to cervical resection, shortening of vaginal length, vaginal atrophy and thinning caused by radiation therapy; at the same time, psychological factors also reduce the quality of patients’ sexual life [27]. In the two groups of patients in this study, few patients had resumed their sexual life half a year after surgery, and their postoperative sexual life quality was low. Patients generally worry that the resumption of their sexual life will affect the healing of the vaginal stump and even think that resuming their sexual life may increase the recurrence rate of their CC [28, 29], which is related to the conservative sexual concepts of Chinese women and other factors. Although the researchers in the intervention group repeatedly explained in the PEI group that sexual life could gradually resume after the vaginal stump was healed, the patients were still very worried and did not dare to resume their sexual life. Sexual activity promotes happiness, self-esteem and general resilience and can strengthen the coping, persistence and survival skills of people with chronic diseases. Research also shows that a satisfying sexual life may reduce morbidity and even mortality in patients [30]. Therefore, in future medical care work, medical staff in China should aim to reduce the physical impact on sexual life, publicize the importance of sexual health, and provide patients with a correct understanding of sexual life. Combining the theory of positive psychology and sexual health guidance can promote restorative behavior among patients and improve their QoL and that of their partners.
During the rehabilitation process, medical staff provided affective and cognitive elaboration of the experiences related to the illness, mood improvement, stress management, problem solving and coping strategies. Patients in the intervention group accompanied and encouraged each other and worked together. Therefore, the practical support was significantly higher than that of the control group. Although they had the same number of close friends, patients in the intervention group obtained more emotional support and positive social interaction during the study and had a better medical and social support system, and their social functioning was also better.
The information for patients in the intervention group came from the researchers. If information was received from other channels, it should be confirmed by researchers before implementation. The inconsistency subscale and ambiguity subscale scores of patients who underwent the PEI intervention were relatively low. The patients in the intervention group obtained a deeper understanding of the disease. When they encountered problems, the members helped and encouraged each other to overcome the disease together as a group. They were more certain and confident about the prognosis of the disease, so the unpredictability subscale and the overall uncertainty level of the disease were lower.
In this study, the patients who underwent the psychoeducational intervention program had better social support and a lower sense of disease uncertainty. Disease uncertainty refers to patients’ lack of ability to determine things related to the disease, resulting in negative emotions interfering with patients’ ability to seek relevant information and even leading to behavioral degradation and termination of treatment [31]. Nursing staff, family members and friends are part of patients’ social support, and their support is negatively correlated with patients’ sense of disease uncertainty. Patients who receive more social support have a lower sense of disease uncertainty [32]. During the PEI program, the care, information sharing and encouragement between nursing staff and patients reduced the uncertainty of the disease, improved social support, and promoted the physical, mental and social recovery of patients in the intervention group.
Due to time constraints, only 63 patients were successfully included in this study, including 31 patients in the intervention group, which is a small sample size. Although the group forms of PEI can promote the rehabilitation of CC patients, the workload of medical staff in China’s third-grade hospitals is generally full, and routine work has occupied the time and energy of medical staff. At present, this program is only carried out in one third-grade hospital, and whether it can be widely carried out in large hospitals with a larger number of CC patients needs to be further verified by multicenter studies with larger sample sizes.
5. Conclusions
This randomized controlled trial shows that the PEI program for patients with CC can promote physical and mental rehabilitation, and the patients were very receptive and engaged. Currently, supportive care for cervical cancer patients in China has not been satisfactory. The implementation of a psychoeducational intervention program can actively provide nursing measures and fill the practice gap. The sample size of this study was small, and the study was conducted in only one large hospital. Subsequent studies can expand the sample size, conduct multicenter studies, and extend the follow-up time to further confirm the feasibility and effectiveness of this project.
Availability of data and materials
The data from this study are contained within this article. Additional data are available upon request from the corresponding author.
Author contributions
JHD and YJ—designed the research study. YJ, JL, SJW and JFW—performed the research. JFW and JJC—analyzed the data. YJ and JHD—wrote the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Ethical approval was obtained from the Ethics Committee of the First Affiliated Hospital of Chongqing Medical University, registration number 2021 (2021-329). Participants would be kept informed of the information related to the study and the progress of the study, and would voluntarily decide whether to participate or not. After participation, participants could choose to withdraw from the study at any time without informing the investigator for any reason, regardless of whether the injury occurred and whether it was serious.
Acknowledgment
We would like to thank all study participants for their considerable support and assistance.
Funding
Nursing Research Fund of the First Affiliated Hospital of Chongqing Medical University: HLJJ: 2018-04.
Conflict of interest
The authors declare no conflict of interest.
