Cui BY, Zhang Z. Impact of anxiety and depression on quality of life in gastric cancer patients receiving SOX neoadjuvant chemotherapy. World J Gastrointest Oncol 2026; 18(7): 119170 [DOI: 10.4251/wjgo.119170]
Corresponding Author of This Article
Zhen Zhang, Lecturer, Department of Thoracic Surgery, The Second Affiliated Hospital of Kunming Medical University, No. 374 Dianmian Avenue, Wuhua District, Kunming 650000, Yunnan Province, China. 15987129313@163.com
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Ophthalmology
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Cui BY, Zhang Z. Impact of anxiety and depression on quality of life in gastric cancer patients receiving SOX neoadjuvant chemotherapy. World J Gastrointest Oncol 2026; 18(7): 119170 [DOI: 10.4251/wjgo.119170]
Author contributions: Cui BY and Zhang Z contributed to the study conception and design; Zhang Z performed analysis, material preparation, data collection; Cui BY was written the first draft of the manuscript. Cui BY and Zhang Z critically revised and approved the final version of the manuscript.
AI contribution statement: In this manuscript, we only use Grammarly and DeepL for English polishing and translation assistance. No AI tools were used to generate any parts of the main text, design research, interpret results, or generate images.
Institutional review board statement: This study was reviewed and approved by Medical Ethics Committee of the Second Affiliated Hospital of Kunming Medical University.
Informed consent statement: All research participants or their legal guardians provided written informed consent prior to study registration.
Conflict-of-interest statement: No conflict of interest is associated with this work.
Data sharing statement: No other data available.
Corresponding author: Zhen Zhang, Lecturer, Department of Thoracic Surgery, The Second Affiliated Hospital of Kunming Medical University, No. 374 Dianmian Avenue, Wuhua District, Kunming 650000, Yunnan Province, China. 15987129313@163.com
Received: January 20, 2026 Revised: February 3, 2026 Accepted: March 10, 2026 Published online: July 15, 2026 Processing time: 174 Days and 1.2 Hours
Abstract
BACKGROUND
Gastric cancer (GC) is a leading cause of cancer mortality globally. The SOX neoadjuvant chemotherapy regimen is standard for early-to-mid-stage disease, but chemotherapy-related stress often induces psychological distress.
AIM
To investigate the prevalence, risk factors of anxiety and depression in stage II-III GC patients receiving SOX neoadjuvant chemotherapy, and clarify their independent impacts on quality of life (QoL).
METHODS
A retrospective analysis was conducted on 153 patients with stage II-III GC receiving SOX regimen NACT at The Second Affiliated Hospital of Kunming Medical University Hospital. Anxiety and depression were assessed using the Zung Self-Rating Anxiety (SAS) and Zung Self-Rating Depression Scale (SDS) scales. QoL was evaluated with the QoL Questionnaire Core 30 questionnaire. Demographic, clinical data, and adverse reactions were collected. Multivariate logistic regression identified risk factors for anxiety/depression. Multiple linear regression analyzed the independent impact of psychological distress on global QoL.
RESULTS
The prevalence of anxiety (SAS ≥ 50) and depression (SDS ≥ 53) was 37.91% (58/153) and 39.87% (61/153), respectively; 47.71% (73/153) had either symptom (anxiety-depression group). Independent risk factors for anxiety/depression included female gender [odds ratio (OR) = 2.13, 95% confidence interval (CI): 1.03-4.40], unmarried/divorced/widowed status (OR = 3.17, 95%CI: 1.28-7.85), primary school education or below (OR = 3.50, 95%CI: 1.33-9.21), and clinical stage III (OR = 2.69, 95%CI: 1.32-5.46). The anxiety-depression group had higher Grade III–IV gastrointestinal reactions (20.55% vs 8.75%, P = 0.021). SAS/SDS scores negatively correlated with emotional (r = -0.552/-0.599), social (r = -0.403/-0.471), physical functioning (r = -0.369/-0.404), and global QoL (r = -0.539/-0.574, all P < 0.001). After adjusting confounders, anxiety (β = -0.12, P = 0.013) and depression (β = -0.14, P < 0.001) independently predicted lower global QoL.
CONCLUSION
Anxiety and depression are common in early-to-mid-stage GC patients receiving SOX neoadjuvant chemotherapy, associated with specific demographic/clinical factors, severe gastrointestinal reactions, and poor QoL, highlighting the need for routine psychological screening and intervention.
Core Tip: This study reveals that nearly half of the patients with early-to-mid-stage gastric cancer undergoing neoadjuvant chemotherapy experience anxiety or depression. These conditions are more common in females, those without spousal support, the less educated, and those with advanced-stage disease. Critically, psychological distress is independently linked to more severe gastrointestinal reactions and a significantly poorer quality of life. Our findings underscore the urgent need for integrating routine psychological screening and support into the standard management protocol for these patients to address both mental and physical well-being.
Citation: Cui BY, Zhang Z. Impact of anxiety and depression on quality of life in gastric cancer patients receiving SOX neoadjuvant chemotherapy. World J Gastrointest Oncol 2026; 18(7): 119170
Gastric cancer (GC) is one of the most common malignant tumors worldwide[1]. The incidence and mortality rates of GC are both among the highest, seriously threatening human life and health[2,3]. For patients with early-stage GC, surgical intervention remains the cornerstone of curative treatment[4]. However, surgery alone may fail to achieve satisfactory tumour eradication in some cases, and carries a relatively high risk of postoperative recurrence[5]. In recent years, the application of neoadjuvant chemotherapy in the treatment of GC has become increasingly widespread[6]. By administering chemotherapy prior to surgery, this approach effectively reduces tumour size and lowers tumour staging, thereby improving surgical resection rates and the likelihood of achieving curative resection[7]. Combination chemotherapy regimens, exemplified by the oxaliplatin and tegafur combination (SOX regimen), have gained widespread adoption in clinical practice owing to their marked efficacy in tumour shrinkage, reduction of clinical stage, and improvement in surgical resection rates[8,9]. Compared with other regimens, SOX is characterized by its oral administration convenience and reduced myelosuppression risk, but its 21-day treatment cycle requires sustained patient adherence to oral dosing and frequent hospital visits for efficacy and safety monitoring. For patients receiving SOX neoadjuvant chemotherapy, unique psychological stressors emerge throughout the treatment course: Persistent gastrointestinal symptoms (nausea, diarrhoea) may erode treatment confidence; the prolonged waiting period between chemotherapy cycles and surgery amplifies anxiety about treatment response and tumour progression; and the cumulative burden of repeated adverse reactions and functional decline further exacerbates depressive symptoms, which are often overlooked in routine clinical management[10]. Against this backdrop, the mental health status of patients has become a clinical issue that cannot be ignored in the comprehensive management of tumors.
In the field of oncology, the psychosocial adaptation of patients is closely related to their clinical outcomes[11]. A large number of studies have shown that anxiety and depression are the most common psychological troubles among cancer patients[12,13]. These negative emotions not only diminish patients' treatment adherence and quality of life (QoL), but may also exert potential adverse effects on tumour progression and prognosis through neuroendocrine and immunoregulatory pathways[14]. Although research into the psychological state of patients with cancers such as breast and lung cancer has now reached considerable depth, studies specifically focusing on the cohort of early- to mid-stage GC patients undergoing neoadjuvant chemotherapy remain relatively scarce[15,16]. This specific cohort of patients finds themselves at a critical juncture in their treatment journey. They harbour hopes of achieving downstaging through neoadjuvant therapy to secure surgical opportunities, while simultaneously grappling with anxieties regarding their response to chemotherapy and future survival prospects. Their unique psychological experiences and needs demand systematic assessment and attention.
Therefore, this study aims to systematically investigate the prevalence and severity of anxiety and depressive symptoms among patients with early-stage GC undergoing SOX neoadjuvant chemotherapy through retrospective analysis. Building upon this, we will further explore the association between anxiety and depressive states and various dimensions of patients’ QoL, quantifying the extent to which psychological factors influence QoL. The findings of this study are expected to provide clinicians with a clear perspective on the necessity of routine psychological screening and timely intervention in this patient population. This will ultimately advance the practice of an integrated medical model addressing both physical and psychological aspects in GC treatment, thereby enhancing patients' overall health outcomes.
MATERIALS AND METHODS
Patient population
This retrospective analysis was conducted on patients with early-to-mid-stage GC treated at The Second Affiliated Hospital of Kunming Medical University Hospital between January 2020 and January 2025, all of whom received neoadjuvant chemotherapy using the SOX regimen. Following rigorous screening, data from 153 patients were ultimately included for statistical analysis. This study strictly adhered to all principles of the Declaration of Helsinki. It received approval from our hospital's Medical Ethics Committee. All patient clinical records were sourced from the hospital's electronic medical record system and follow-up database, with personal information anonymised to safeguard patient privacy.
Inclusion and exclusion criteria
Inclusion criteria: (1) Age ≥ 18 years; (2) Histologically confirmed gastric adenocarcinoma, clinically staged cT2-4aN0-3M0 (AJCC 8th edition stage II-III)[17]; (3) First-line antineoplastic therapy with a defined neoadjuvant chemotherapy regimen of the SOX protocol (oxaliplatin 130 mg/m² intravenous infusion on day 1; S-1 40-60 mg/m² orally twice daily on days 1-14, every 21 days), with ≥ 2 completed cycles; (4) Completion of at least one anxiety/depression assessment and QoL evaluation during neoadjuvant chemotherapy and within one month post-chemotherapy, with complete data; and (5) Availability of comprehensive clinical medical records.
Exclusion criteria: (1) History of psychiatric disorders or current use of anti-anxiety/antidepressant medications; (2) Concurrent primary malignancies in other organs; (3) Interruption or regimen modification of neoadjuvant chemotherapy due to severe adverse reactions (e.g., ≥ grade 3 myelosuppression, severe allergic reactions); and (4) Severe dysfunction of major organs including heart, liver, or kidneys.
Data collection
Clinical data were systematically extracted from the hospital's electronic medical record system and cancer patient follow-up database by two uniformly trained clinical researchers through independent double-entry. Discrepancies were resolved through joint consultation with a third senior researcher to ensure data accuracy. The collected data included two categories: (1) Demographic and clinical characteristics: Age, gender, body mass index (BMI), marital status, educational level, tumour size, number of lymph node metastases, pathological type, degree of differentiation, human epidermal growth factor receptor 2 (HER2) status, and clinical stage (AJCC 8th edition); and (2) Psychological assessment results, chemotherapy adverse reaction records, and QoL scores during neoadjuvant chemotherapy and within one month after chemotherapy. All patient information was anonymized during data extraction to protect privacy, and the entire process strictly complied with the requirements of the Declaration of Helsinki and the hospital’s medical ethics committee.
Research scale
Anxiety and depressive symptoms were assessed using the Zung Self-Rating Anxiety Scale (SAS)[18] and the Zung Self-Rating Depression Scale (SDS)[19], respectively. Both scales are widely used, validated self-report instruments comprising 20 items each, scored on a Likert scale from 1 to 4. The total raw scores are converted to standard scores by multiplying by 1.25. For anxiety, a standard SAS score ≥ 50 was defined as symptomatic anxiety, with severity categorized as follows: Mild (50-60), moderate (61-70), and severe (> 70). For depression, a standard SDS score ≥ 53 was defined as symptomatic depression, categorized as mild (53-62), moderate (63-72), and severe (> 72). Patients were classified into the anxiety-depression group if they met the cutoff for either anxiety or depression. This combined grouping approach, commonly used in oncological research, aims to identify patients with clinically significant psychological distress of any type, recognizing the high comorbidity and overlapping symptomatology between anxiety and depression in cancer settings[20,21].
QoL was evaluated using the QoL Questionnaire Core 30 (QLQ-C30) version 3.0 developed by the European Organisation for Research and Treatment of Cancer (EORTC)[22,23]. The QLQ-C30 includes five functional scales (physical, role, emotional, cognitive, social), three symptom scales, a global health status/QoL scale, and several single items. The raw scores were linearly transformed to a 0-100 scale according to the EORTC scoring manual. Higher scores on the functional and global QoL scales indicate better functioning and QoL.
Statistical analysis
Statistical analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, United States). Continuous variables with non-normal distribution were presented as median with interquartile range (M [Q1, Q3]) and compared using the Mann-Whitney U test. Categorical variables were expressed as n (%) and compared using the χ2 test or Fisher’s exact test as appropriate. The prevalence and severity of anxiety and depression were summarized descriptively. Univariate logistic regression was used to screen potential factors associated with anxiety/depression. Variables with a significance level of P < 0.10 in univariate analysis were included in a multivariate logistic regression model using a backward stepwise selection method to identify independent risk factors. Results were expressed as odds ratios (OR) with 95% confidence intervals (CI). The discriminative ability of the final model was evaluated using the area under the curve (AUC), and calibration was assessed by the Hosmer-Lemeshow test and a calibration plot. The association between anxiety/depression and adverse reactions was analyzed using the χ2 test. Pearson correlation analysis was conducted to examine the relationships between anxiety/depression scores and various QoL domains. Multiple linear regression was employed to assess the independent impact of anxiety and depression on global QoL scores, with adjustment for potential confounders including gender, marital status, educational level, clinical stage, and adverse reactions. Variance inflation factors were checked to exclude multicollinearity. A two-tailed P < 0.05 was considered statistically significant.
RESULTS
Prevalence and severity of anxiety and depressive symptoms
A total of 153 patients with early-to-mid-stage GC undergoing neoadjuvant chemotherapy were included in the final analysis. As detailed in Table 1, the prevalence of anxiety symptoms (SAS ≥ 50) was 37.91% (58/153), with the majority of cases being mild (54/58, 93.1%) and only 4 (6.9%) classified as moderate. No severe anxiety cases were reported. Similarly, the prevalence of depressive symptoms (SDS ≥ 53) was 39.87% (61/153), distributed as 49 mild (80.3%) and 12 moderate (19.7%) cases, with no severe depression. Based on the composite criterion (SAS ≥ 50 or SDS ≥ 53), 73 patients (47.71%) were categorized into the anxiety-depression group for subsequent analyses.
Table 1 Detection rates and severity of anxiety and depression symptoms, n (%).
Univariate analysis of factors associated with anxiety and depression
The intergroup comparisons of demographic and clinical characteristics between the normal group (n = 80) and the anxiety-depression group (n = 73) are presented in Table 2. No statistically significant differences were observed between the two groups in terms of age, BMI, tumor size, number of lymph node metastases, pathological type, differentiation grade, or HER2 status (P > 0.05). However, significant differences were identified in gender (P = 0.023), marital status (P = 0.012), educational level (P = 0.028), and clinical stage (P = 0.003). Specifically, female patients, those who were unmarried/divorced/widowed, those with lower education levels, and those with clinical stage III disease demonstrated a higher likelihood of experiencing anxiety or depression.
Table 2 Intergroup comparison of factors related to anxiety/depression, n (%).
Independent risk factors for anxiety and depression identified by multivariate logistic regression
Variables with P < 0.10 from the univariate analysis were entered into a multivariate logistic regression model using a backward stepwise method. The final model, summarized in Table 3, identified four independent risk factors for anxiety and depression: Female gender (OR = 2.13, 95%CI: 1.03-4.40, P = 0.040), being unmarried/divorced/widowed (OR = 3.17, 95%CI: 1.28-7.85, P = 0.013), lower education level (primary school or below vs above high school: OR = 3.50, 95%CI: 1.33-9.21, P = 0.011), and advanced clinical stage (stage III vs stage I/II: OR = 2.69, 95%CI: 1.32-5.46, P = 0.006).
Table 3 Multivariate regression model of independent risk factors for anxiety/depression.
Evaluation of the multivariable logistic regression model
The receiver operating characteristic curve analysis (Figure 1A) demonstrated that the model had good discriminative ability, with an AUC of 0.73 (95%CI: 0.65-0.81). This indicates a satisfactory capacity to distinguish between patients with and without clinically significant anxiety or depression. Furthermore, the calibration curve (Figure 1B) showed a close alignment between the predicted probabilities of having anxiety/depression and the actual observed frequencies. The goodness-of-fit was confirmed by a non-significant Hosmer-Lemeshow test statistic (P = 0.967), indicating that the model’s predictions were not significantly different from the observed outcomes and that the model was well-calibrated.
Figure 1 Evaluation of the prediction model.
A: Receiver operating characteristic curve analysis; B: Calibration curve analysis. AUC: Area under the curve.
Association between anxiety/depression and chemotherapy-induced adverse reactions
We further investigated the relationship between psychological state and the severity of common chemotherapy-related adverse reactions (Table 4). A statistically significant association was found between the anxiety-depression group and the severity of gastrointestinal reactions (P = 0.021). Patients in the anxiety-depression group experienced a higher proportion of Grade III–IV gastrointestinal reactions (20.55%, 15/73) compared to those in the normal group (8.75%, 7/80). No significant associations were observed for the severity of myelosuppression, hematological toxicity, or neurotoxicity between the two groups (all P > 0.05).
Table 4 Association between anxiety and depression and adverse reactions during chemotherapy, n (%).
Correlation between anxiety/depression and QoL dimensions
Pearson correlation analysis was performed to explore the relationships between SAS/SDS scores and various domains of the QLQ-C30 (Table 5). Both anxiety and depression scores showed statistically significant negative correlations with the emotional functioning (r = -0.552 and -0.599, respectively, P < 0.001) and social functioning (r = -0.403 and -0.471, respectively, P < 0.001) domains. Negative correlations were also observed with physical functioning (anxiety: R = -0.369; depression: R = -0.404, P < 0.001). Consequently, the global QoL total score was strongly and inversely correlated with both anxiety (r = -0.539, P < 0.001) and depression (r = -0.574, P < 0.001).
Table 5 Multi-dimensional correlation between anxiety, depression and quality of life.
To quantify the independent impact of anxiety and depression on global QoL, multiple linear regression analyses were conducted (Table 6). In the crude model, both higher SAS scores (β = -0.25, P < 0.001) and higher SDS scores (β = -0.20, P < 0.001) were significant predictors of lower global QoL scores. After adjusting for potential confounders including gender, marital status, educational level, clinical stage, and adverse reactions, both anxiety (β = -0.12, P = 0.013) and depression (β = -0.14, P < 0.001) remained independently and negatively associated with the global QoL total score.
Table 6 Multiple linear regression analysis of the impact of anxiety/depression on quality of life.
Globally, GC is not only a physiological disease, but its diagnosis and treatment process also bring huge psychological and social burdens[24]. This study focused on patients with early-stage GC undergoing neoadjuvant chemotherapy, systematically investigating the prevalence of anxiety and depressive symptoms, associated influencing factors, and their relationship with QoL. The principal findings of this study may be summarised in four points: Firstly, among patients with early- to mid-stage GC undergoing SOX neoadjuvant chemotherapy, the detection rate of clinically significant anxiety or depressive symptoms reached 47.7%, with independent detection rates of 37.9% and 39.9% for anxiety and depression respectively, predominantly presenting as mild to moderate symptoms. Secondly, female gender, unmarried/divorced/widowed status, lower educational attainment, and clinical stage III disease constituted independent risk factors for anxiety and depression. Thirdly, patients in the psychological distress group exhibited a significantly elevated risk of grade 3-4 gastrointestinal adverse reactions, with an overall trend towards worsening adverse reaction profiles. Fourthly, anxiety and depression exhibited significant negative correlations with all dimensions of QoL. Their independent impact remained pronounced even after adjusting for demographic and clinical-pathological confounders, with the most marked impairment observed in emotional, social, and bodily functioning. These findings not only fill a gap in research on the psychological status of patients undergoing neoadjuvant chemotherapy for early-to-mid-stage GC but also provide evidence-based support for establishing an integrated ‘bio-psycho-social’ model for GC diagnosis and treatment.
Firstly, regarding the influencing factors of anxiety and depression, the results of our multivariate Logistic regression analysis are consistent with existing studies. Han’s research[25] shows that the prevalence rates of anxiety and depression among GC patients are 42.5% and 33.5% respectively, significantly higher than those among healthy people. The detection rates of anxiety and depression in the patients of this study were 37.91% and 39.87% respectively. Although they were higher than those in the general population, they were lower than those in patients with advanced GC and recurrent GC[24,26]. The reason might stem from the fact that patients are simultaneously subjected to the life-threatening threat of cancer diagnosis, the side effects of treatment, and the huge psychological impact brought by the uncertainty of the future[27]. The four independent risk factors identified in this study possess clear clinical and sociodemographic significance. Female patients with GC are more prone to emotional disorders, which was also reported in the study by Han[25] and Kwon et al[28]. From a physiological perspective, fluctuations in female sex hormone levels may influence neurotransmitter secretion, potentially leading to relatively weaker emotional regulation capabilities[29]. Marital status is generally regarded as a significant source of social support[30]. The absence of spousal support may result in patients lacking effective emotional comfort and practical assistance when coping with the pressures of illness and treatment, thereby increasing psychological vulnerability[31]. Patients with lower educational attainment may have more misunderstandings and fears about the disease and treatment, and their ability to obtain and utilize psychosocial resources is relatively limited, which is consistent with the results of a survey conducted by Hong and Tian[32] on the Chinese population. Moreover, compared to patients diagnosed at earlier stages, those in stage III present a heavier tumour burden. This more severe disease reality undoubtedly exacerbates the psychological burden on patients[33]. The identification of these factors assists clinicians in rapidly screening high-risk populations for psychological issues, thereby enabling more targeted early psychological intervention and support.
This study found that the incidence of grade III-IV gastrointestinal reactions in patients with anxiety/depression (20.55%) was significantly higher than in the normal group (8.75%), whereas myelosuppression, haematological toxicity, and neurotoxicity showed no significant association with psychological status. Gastrointestinal reactions (such as nausea, vomiting, and diarrhoea), being the most common toxic side effects of the SOX regimen, may induce or exacerbate negative emotions in patients due to their persistence and severity[34]. On the other hand, negative emotions such as anxiety and depression can be regulated through the neuro-endocrine-immune network, heightening gastrointestinal sensitivity and exacerbating chemotherapy-induced damage to the gastrointestinal mucosa, thereby forming a vicious “psycho-physiological” cycle[35]. This suggests that when managing adverse reactions to chemotherapy, attention should not be confined solely to the toxicity of the drugs themselves; the patient’s psychological state must also be incorporated into the assessment framework. Active psychological interventions may serve as an adjunct strategy to alleviate specific adverse effects of chemotherapy.
Correlation analysis and multiple linear regression results consistently indicate that anxiety and depression exert a comprehensive and profoundly negative impact on patients’ QoL. The strong negative correlation between the two and emotional and social functions is particularly worthy of attention, indicating that psychological distress seriously interferes with patients' emotional regulation ability and normal social interaction. Multiple studies have shown that there is a close connection between anxiety and social function, and it can affect the QoL of patients[36-38]. Moreover, the negative correlation with physical functioning suggests that psychological issues may limit patients' capacity for daily activities by affecting their motivation, energy levels, or perception of physical discomfort[39]. Ultimately, impairment across these functional domains collectively results in a marked decline in the patient's global QoL. Our study quantifies this impact, demonstrating that anxiety and depression remain independent negative predictors of global QoL even after controlling for potential confounding factors such as gender, marital status, educational attainment, clinical stage, and adverse reactions. This provides compelling evidence that improving psychological well-being holds irreplaceable value in enhancing the overall health outcomes of patients undergoing neoadjuvant chemotherapy for GC.
Based on the findings of this study, we propose the following clinical practice recommendations: (1) Firstly, routine screening for anxiety and depression (e.g., using the SAS and SDS scales) should be implemented for all GC patients undergoing neoadjuvant chemotherapy, particularly within the high-risk population identified in this stud; (2) Secondly, for patients screening positive, a multidisciplinary psychological support system should be established, integrating resources from oncologists, nurses, psychologists, and social workers to provide individualised support programmes ranging from psychological education and cognitive behavioural therapy to necessary psychopharmacological interventions; and (3) Finally, adverse reaction management should adopt a ‘mind-body co-treatment’ approach, recognising the interaction between psychological state and physical symptoms. For patients with significant anxiety/depression, enhanced prophylaxis and management of gastrointestinal reactions should be implemented proactively. This study also presents several limitations. Firstly, as a single-centre retrospective investigation, it carries an inherent risk of selection bias, and the generalisability of its conclusions requires further validation through multicentre prospective studies. Secondly, psychological assessments primarily relied on patient self-report questionnaires; future research may integrate clinician-administered tools to obtain more comprehensive information on psychological status. Thirdly, assessments were conducted solely during chemotherapy and within one month post-treatment, failing to dynamically track the evolution of patients' psychological status and QoL over extended treatment cycles (e.g., post-surgery). Finally, the study primarily explored correlations; the actual efficacy of psychological interventions in improving QoL and clinical outcomes requires confirmation through subsequent rigorously designed randomised controlled trials.
CONCLUSION
In summary, this study reveals that anxiety and depressive symptoms are prevalent among patients with early-to-mid-stage GC undergoing SOX neoadjuvant chemotherapy. These symptoms are closely associated with female gender, lack of marital support, lower educational attainment, and advanced clinical staging. Such psychological distress not only correlates with more severe gastrointestinal adverse reactions but also constitutes an independent risk factor for diminished QoL. Therefore, integrating systematic psychological assessment and support into the routine management of patients undergoing neoadjuvant chemotherapy for GC represents a crucial step towards realising the transition to a biopsychosocial medical model and ultimately improving overall patient outcomes.
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