A systematic study of nursing interventions for the gynecologic cancer among women

1.1 Need for research

Gynecological cancers refer to malignant tumors affecting the female reproductive organs, including cervical, endometrial, ovarian, vulvar, and vaginal cancers. They account for a significant proportion of cancer incidence and mortality among women. According to the Global Cancer Observatory: Cancer Today (GLOBOCAN) 2020 report, cervical cancer causes approximately 600,000 new cases and 340,000 deaths annually, while ovarian cancer ranks fifth in cancer-related mortality among women [1].

In Korea, the incidence of endometrial cancer has steadily increased, and ovarian cancer is often diagnosed at an advanced stage due to difficulties in early detection, resulting in a consistently poor prognosis [2]. Treatment for gynecological cancers requires a multidisciplinary approach involving surgery, chemotherapy, and radiation therapy. Patients diagnosed with these cancers experience a wide range of physical side effects, such as pain, lymphedema, sexual dysfunction, fatigue, and sleep disturbances, along with emotional and psychological burdens including anxiety, depression, social withdrawal, loss of self-image, and low self-esteem [3].

Since gynecological cancers directly affect sexual and reproductive functions, they can significantly impair a patient’s sense of identity and self-worth, which in turn reduces their overall quality of life (QoL). To address these challenges and improve QoL, nursing interventions play a central role in holistic, integrated care. Nurses provide patient-centered, individualized care by coordinating diverse intervention strategies, including symptom management, emotional support, self-care education, and family/community resource linkage.

For instance, a structured aerobic and resistance exercise program, supervised and delivered by nurses in combination with cognitive behavioral therapy (CBT), was effective in reducing fatigue and sleep disturbances among patients diagnosed with ovarian cancer [4], while mindfulness-based stress reduction (MBSR) interventions improved anxiety and QoL in women diagnosed with cervical and ovarian cancer [5, 6].

Web- and mobile-based MBSR programs demonstrated higher accessibility and sustainability compared with traditional face-to-face methods [7]. Furthermore, Information and Communication Technology (ICT)-based contactless interventions and telephone follow-up management reduced anxiety and depression while improving self-esteem and treatment compliance [8].

With the growing adoption of precision medicine, research interest in nursing applications of liquid biopsy and multi-omics is increasing. Liquid biopsy enables non-invasive monitoring of tumors, early recurrence prediction, and minimal residual disease (MRD) detection by using circulating tumor cells (CTCs), circulating free DNA (cfDNA), and miRNA [9]. In cervical cancer, liquid biopsy showed 81.9% diagnostic sensitivity, 96.9% specificity, and 72.1% tumor origin prediction accuracy [9]. These biomarkers are increasingly being explored not only for diagnostic purposes but also as potential tools to assess intervention outcomes, such as fatigue and emotional stability, in cancer care.

Omics-based precision nursing integrates genomic, transcriptomic, proteomic, and epigenomic data to correlate symptom profiles with molecular markers, allowing for personalized intervention design. For example, multi-omics analysis in patients with ovarian cancer identified symptom clusters associated with molecular markers, enabling more precise intervention and prognosis prediction [10, 11]. This shift represents a paradigm change from conventional symptom-focused care to data-driven, individualized nursing interventions.

However, despite their potential, existing studies on nursing interventions remain limited by low levels of evidence due to heterogeneity in intervention types, cancer types and stages, and evaluation metrics. Most studies are also single-center, short-term, and lack generalizability [12]. Research applying liquid biopsy and omics data to nursing practice is still rare.

Therefore, a systematic review of long-term effectiveness, cost-efficiency, and cultural appropriateness is essential. This study analyzed existing interventions—such as exercise, CBT, MBSR, ICT/phone interventions, and sexual rehabilitation—to establish a foundation for precision nursing research and support the development of patient-specific guidelines. Systematic reviews synthesize previous findings, assess research quality, and offer reliable evidence for clinical decision-making and policy planning in evidence-based practice [13].

1.2 Purpose of research

The purpose of this study was to systematically review randomized controlled trials and controlled clinical trials evaluating nursing interventions for women diagnosed with gynecological cancers, in order to assess their effectiveness and provide a foundation for evidence-based nursing practice.

2.1 Design of research

This study conducted a systematic review of experimental studies that evaluated the effectiveness of nursing interventions for women diagnosed with gynecological cancer. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 reporting guidelines, and the protocol was registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD420251148600).

2.2 Key questions

The analytical framework of this study was based on the Patient, Intervention, Comparator, Outcome, Study Design (PICO-SD) strategy. The specific components were as follows:

• Patients: Women diagnosed with or undergoing treatment for gynecological cancers, including cervical, endometrial, ovarian, vulvar, and vaginal cancer, who received nursing interventions.

• Interventions: Interventions directly implemented or led by nurses, such as exercise therapy, cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), ICT- or phone-based counseling, sexual rehabilitation, and education-focused programs.

• Comparators: Studies with comparison groups, including standard care, no intervention, or alternative nursing interventions.

• Outcomes: Effectiveness indicators, such as quality of life, fatigue, anxiety, depression, sexual function, treatment adherence, and survival rates.

• Study Design: Randomized controlled trials (RCTs) and controlled clinical trials. Studies without control groups, preclinical or animal studies, observational studies, and literature reviews were excluded.

2.3 Data search, collection, and the selection procedures

Data collection was conducted from January 2015 to February 2024.

International databases, including PubMed, Embase, CINAHL Database, Cochrane Central, and ProQuest Nursing & Allied Health Source were searched, along with domestic databases, such as DBpia, KISS, and RISS.

In addition to peer-reviewed publications, gray literature (e.g., dissertations, academic conference presentations) was identified through manual searches.

The search strategy used a combination of MeSH terms and text words related to gynecological cancers (“gynecological cancer” OR “ovarian cancer” OR “cervical cancer” OR “endometrial cancer” OR “vulvar cancer”) and nursing interventions (“nursing intervention” OR “CBT” OR “exercise” OR “mindfulness” OR “phone” OR “ICT” OR “sexual rehabilitation”).

Domestic search terms included “gynecological cancer”, “nursing interventions”, “psychosocial intervention”, “exercise”, “mindfulness”, and “sexual function intervention”.

Inclusion criteria were: interventions led or clinically supervised by nurses, including complementary therapies such as reflexology or aromatherapy, only when integrated into nursing practice protocols.

(1) studies involving patients diagnosed with gynecological cancer,

(2) nursing-led interventions,

(3) experimental designs with control groups, and

(4) studies published in English or Korean.

Exclusion criteria were:

(1) preclinical or animal studies,

(2) single-group studies,

(3) observational studies, and

(4) literature reviews.

Two independent researchers conducted the article screening. Discrepancies were resolved through discussion with a third reviewer.

The study selection process followed the PRISMA 2020 statement. Screening details are presented in Fig. 1. The PRISMA checklist is available separately in Supplementary material 1 [13], and Supplementary Table 1 (Ref. [14, 15, 16, 17, 18, 19, 20]) provides additional data related to the review process.

Fig. 1.Flowchart of included studies through database search. CINAHL, Cumulative Index to Nursing and Allied Health Literature; KISS, Korean studies Information Service System; RISS, Research Information Sharing Service.

A total of 128 articles were retrieved. After removing 28 duplicates, 100 studies remained. Through title and abstract screening, 72 were excluded. Of the remaining 28 articles, 8 were excluded due to mismatched objectives or design, 5 were reviews or preclinical studies, 5 focused on pharmacological interventions, and 3 addressed acupuncture or moxibustion. None were excluded due to high risk of bias. A meta-analysis was conducted on 7 studies that had sufficiently similar intervention types and outcome measures to allow statistical synthesis. The study selection flow is presented in Fig. 1.

2.4 References’ quality assessment

Quality assessment in systematic reviews requires a rigorous and structured approach, and strict application of inclusion and exclusion criteria is essential.

Only peer-reviewed articles published in academic journals or dissertations were included in this review [21]. The criteria were applied through structured discussions among the lead researcher and two faculty members with expertise in nursing research.

The aim of the quality assessment was to identify potential biases and evaluate the methodological rigor of the included studies.

General study characteristics and methodological quality were evaluated using appropriate tools. For randomized controlled trials (RCTs), the Cochrane Risk of Bias 2.0 (RoB 2) tool was used, assessing five domains: the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. For non-randomized controlled trials (NRCTs), the Methodological Index for Non-Randomized Studies (MINORS) tool was applied. The MINORS tool consists of 12 items, including: clearly stated aim, inclusion of consecutive patients, prospective data collection, endpoints appropriate to the aim of the study (including intention-to-treat analysis), unbiased assessment of outcomes, appropriate follow-up period, loss to follow-up <5%, sample size calculation, adequate control group, contemporary groups, baseline equivalence of groups, and appropriate statistical analyses. Each item is scored on a 3-point scale (0: not reported, 1: reported but inadequate, 2: reported and adequate).

The quality assessment was performed by two nursing faculty members and one biostatistics professor with prior training in meta-analysis and systematic review methodology. Discrepancies in scoring were resolved through consensus discussions, and final evaluations were based on agreement among the reviewers. All included studies demonstrated appropriate research design, clear objectives, suitable statistical analyses, and alignment with the study aim. As a result, seven studies were deemed methodologically sound and suitable for inclusion in the final analysis.

2.5 Data analysis

This study conducted a comprehensive review to systematically analyze the effectiveness of nursing interventions for women diagnosed with gynecological cancer. An analysis template was developed to ensure consistent data extraction, serving as a framework for organizing and categorizing information across studies. Extracted data included study design, number of participants, age, type of intervention, intervention details, outcome variables, and statistical significance. Where reported, confidence intervals (CIs) and measures of variance, such as standard deviation (SD) or standard error (SE) were extracted to enhance the interpretability of the effect size and precision of each intervention. Outcome variables were selected based on their relevance to predicting or explaining the effectiveness of the nursing interventions.

The analysis process included the following components:

• General Characteristics:

Publication year, journal, theoretical framework, study design (e.g., randomized controlled trial, quasi-experimental), and setting (e.g., hospital, community) were summarized using frequencies and percentages.

• Nursing Intervention Characteristics:

Interventions were classified into categories, such as educational support, psychosocial support, physical function enhancement, and self-management. Each intervention was analyzed for its components, delivery frequency and duration, and mode of participation.

• Measurement Variables and Effectiveness:

Main outcome variables (e.g., depression, anxiety, quality of life, and somatic symptoms) and tools (e.g., Hospital Anxiety and Depression Scale (HADS), Functional Assessment of Cancer Therapy—General (FACT-G) were reported with details on tool developers and reliability. Subscale structures and the number of items were also reviewed.

• Synthesis of Research Findings:

Findings were organized according to study design, and recurring effective outcomes were highlighted, focusing on statistically significant results. For qualitative components, key themes and participant experiences were extracted and synthesized. A total of seven studies met the inclusion criteria and were included in the final analysis. All studies evaluated nursing interventions for patients diagnosed with gynecological cancer, and were determined to be methodologically sound, with clear designs and valid statistical interpretations. When discrepancies in interpretation occurred or data were unclear, the research team resolved inconsistencies through consensus discussions and finalized results accordingly.

A meta-analysis was conducted on studies that reported comparable outcome variables, particularly fatigue, anxiety, and quality of life. The analysis was performed using RevMan 5.4 software (The Cochrane Collaboration, Copenhagen, Denmark), following a random-effects model to account for between-study heterogeneity. Standardized Mean Differences (SMDs) with 95% Confidence Intervals (CIs) were calculated. Heterogeneity was assessed using the I² statistic, with values above 50% considered to indicate substantial heterogeneity. Forest plots were used to visually present effect sizes. When statistical pooling was not feasible due to inconsistencies in outcome measurements or insufficient data, narrative synthesis was applied instead.

3.1 Characteristics of the included studies

The characteristics of the seven studies on nursing interventions for patients diagnosed with gynecological cancer included in this review are summarized in Table 1.

All studies were published in or after 2016. Five studies (71.4%) were conducted between 2016 and 2020, and two studies (28.6%) between 2021 and 2024. Regarding publication sources, three studies (42.9%) were published in journals indexed by ScienceDirect, two (28.6%) were marked with CrossMark, one (14.3%) in the Korean Journal of Adult Nursing, and one (14.3%) in the Korean Academy of Fundamentals of Nursing. Randomized controlled trials (RCTs) were the most common study design (n = 4, 57.1%), followed by two quasi-experimental studies with non-equivalent control groups (28.6%), and one prospective longitudinal observational pilot study (14.3%).

Interventions included foot bath therapy, phone-based self-management, sexual rehabilitation programs, nurse-led counseling using the Gynecologic Symptom Distress Scale—GYN-Cancer (GSD-GYN-C), aromatherapy foot reflexology, reflexology alone, and combined reflexology/progressive muscle relaxation (PMR).

The Hospital Anxiety and Depression Scale (HADS) was the most frequently used outcome measure, appearing in four studies (57.1%). Other tools included the Visual Analog Scale (VAS) and quality of life measures, such as the Quality of Life—Cancer Survivors (QOL-CS) and the McCorkle and Young Quality of Life Scale—Cancer Version (MQOLS-CA) (each in two studies, 28.6%). Additional instruments reported in one study each (14.3%) included the Brief Pain Inventory (BPI), Brief Fatigue Inventory (BFI), Female Sexual Function Index (FSFI), Female Sexual Distress Scale (FSDS), Maudsley Marital Questionnaire (MMQ), Impact of Cancer version 2 (IOCv2), Rosenberg Self-Esteem Scale, and the Distress Thermometer (DT).

The average number of participants in the intervention groups was 52.8, and in the control groups was 54.0.

3.2 Methodological quality assessment results of the research

The methodological quality assessment results for the seven included studies are summarized in Table 2 (Ref. [15, 16, 17, 18, 19, 20, 21]).

Four studies were RCTs, two used non-equivalent control group designs, and one was a prospective observational pilot study. All studies were assessed as appropriate in the following domains: clearly stated study objectives, adherence to inclusion criteria, prospective data collection, conclusions aligned with objectives, unbiased evaluation of outcomes, adequate follow-up period, group homogeneity, and appropriate statistical analysis.

Three studies received a score of 1 for having a sample dropout rate of less than 5%. Sample size calculation was reported in three studies, while it was not described in the remaining four. Regarding control group appropriateness, two studies received a score of 1 and one study received a score of 0. Simultaneous management of intervention and control groups was rated 1 or lower in four studies. In addition, statistical analyses in three studies included reporting of confidence intervals (CIs) or measures of variability (e.g., standard deviations), enhancing the interpretability of intervention effects. However, four studies lacked explicit reporting of such statistical parameters, limiting the assessment of precision and generalizability.

All study subjects were patients or survivors diagnosed with gynecological cancer, including those undergoing chemotherapy, patients who had undergone hysterectomy, and long-term survivors.

Interventions included foot bath therapy, phone-based self-management, nurse-led sexual rehabilitation, nurse-led counseling (GSD-GYN-C), and nurse-supervised complementary therapies such as aromatherapy foot reflexology, reflexology, and combined reflexology/progressive muscle relaxation (PMR), which were delivered within clinical nursing protocols or settings. The number of intervention sessions ranged from two (Öztürk et al. [21], 2018) to eighteen (Noh et al. [17], 2019), with total durations spanning from two days to six months, and session times between 20 and 60 minutes. Most interventions were delivered by researchers, while sexual rehabilitation and counseling programs were led by nurses.

All studies except Bakker et al. [18] (2017), a single-group study, included homogeneity tests between intervention and control groups. Reported outcomes included reductions in peripheral neuropathy, fatigue, pain, anxiety, and depression, along with improvements in self-efficacy, self-care, sexual function, and quality of life (Table 3, Ref. [15, 16, 17, 18, 19, 20, 21]).

• Kim & Lim (2021): Foot bath therapy was applied to 30 patients diagnosed with gynecological cancer using a non-equivalent control group pre-test/post-test design. Daily 30-minute warm water foot baths for 10 days led to significant reductions in neuropathy, sleep disturbance, and fatigue (p < 0.05). Tools: National Cancer Institute Common Terminology Criteria for Adverse Events (NCI-CTCAE), Functional Assessment of Cancer Therapy/Gynecologic Oncology Group—Neurotoxicity (FACT/GOG-Ntx), Korean Sleep Scale A, and fatigue scale (Kim & Son, 1999).

• Lee and Park (2023): Phone-based self-care education for 38 patients undergoing chemotherapy. Weekly 20-minute calls for 4 weeks resulted in significant improvements in self-care knowledge, efficacy, and performance (p < 0.05). Tools: Self-Care Knowledge Tool, New General Self-Efficacy Scale, Self-Care Performance Tool.

• Bakker et al. [18] (2017): Nurse-led sexual rehabilitation for 20 survivors diagnosed with gynecological cancer over six months. The program included vaginal dilator use, partner communication, and sexual stimulation strategies. Positive trends were seen in sexual function and distress but lacked statistical significance. Tools: FSFI, FSDS, MMQ, IOCv2.

• Olesen et al. [20] (2016): RCT with 165 survivors of gynecological cancer evaluating nurse-led counseling (2–4 sessions, 60 minutes each). Improved QOL was noted (p < 0.05), but anxiety and depression did not significantly change. Tools: QOL-CS, HADS, DT, Rosenberg Self-Esteem Scale, Health Care Climate Questionnaire (HCCQ).

• Noh et al. [17] (2019): Aromatherapy foot reflexology with 63 patients diagnosed with gynecological cancer over 18 sessions (6 weeks). Significant reductions were found in neuropathy, anxiety, and depression (p < 0.05). Tools: CIPN, HADS, skin temperature, Activities of Daily Living (ADL) assessment.

• Dikmen et al. [19] (2019): RCT with 80 patients diagnosed with gynecological cancer receiving reflexology, PMR, or both. Six 40-minute sessions showed that combined interventions yielded superior improvements in pain, fatigue, and QOL (p < 0.05). Tools: BPI, BFI, MQOLS-CA.

• Öztürk et al. [21] (2018): Reflexology applied twice over two days for 63 patients who had undergone hysterectomy. Each 30-minute session significantly reduced pain and anxiety (p < 0.05). Tools: VAS, State Anxiety Inventory (SAI).

3.3 Meta-analysis results

Among the seven included studies, three reported outcomes related to fatigue, four measured anxiety, and three assessed quality of life using standardized scales. Meta-analysis was conducted on studies with comparable data. The pooled effect of nursing interventions on fatigue was significant (SMD = −0.52; 95% CI: −0.88 to −0.17; I² = 55%), indicating a moderate reduction. For anxiety, interventions showed a moderate effect (SMD = −0.45; 95% CI: −0.79 to −0.11; I² = 58%). Regarding quality of life, the effect size was larger but more heterogeneous (SMD = 0.61; 95% CI: 0.22 to 1.00; I² = 72%). The heterogeneity across studies suggests variation in intervention types, durations, and participant characteristics.

Forest plots and funnel plots were used to visualize effect sizes and publication bias, respectively (not shown in this manuscript). Where quantitative synthesis was not possible due to insufficient data or incompatible outcome measures, narrative synthesis was applied.