Construction of a psychological intervention program to support fear of recurrence in patients with cervical cancer

Abstract

BACKGROUND

Cervical cancer, a prevalent gynecological malignancy, exhibits recurrence rates of 30%-50% post-treatment, with recurrent cases facing a dire 10%-20% long-term survival rate, severely impacting patients’ mental health and quality of life. Fear of cancer recurrence (FCR) emerges as a critical psychological challenge, often leading to anxiety, social avoidance, and even suicidal tendencies. Despite its high prevalence, structured, evidence-based interventions for FCR in cervical cancer remain scarce, with most studies focusing on general psychological support rather than targeted strategies. The fear of progression theory provides a theoretical framework, highlighting cognitive-emotional conflicts arising from perceived threats of disease recurrence. Addressing this gap, this study developed a specialized, phased psychological intervention program grounded in fear of progression theory, aiming to reduce FCR and enhance resilience in cervical cancer survivors through multi-disciplinary strategies.

AIM

To establish a psychological intervention program to support the fear of cervical cancer recurrence and to alleviate the psychological pressure of patients after cervical cancer surgery.

METHODS

Thirteen experts were selected to conduct two rounds of correspondence through literature review and group discussions to amend the psychological intervention draft and form the basis for the psychological intervention. The selected experts also performed two rounds of correspondence to revise the psychological intervention draft and outline the first draft, and pre-experiments were conducted for further improvement of the psychological intervention program. Experiments were performed in 80 patients with cervical cancer to further improve the psychological intervention program of relapse fear support.

RESULTS

The expert authority coefficient of the first and second rounds was higher than 0.8, indicating high authority. The coordination coefficient > 0.8 indicated high consistency with high significance (all P < 0.05). The FCR Inventory, Kessler Psychological Distress Scale, Psychological Distress Thermometer, and General Hospital Anxiety and Depression Scale scores at 3 and 6 months in the study group were lower than those of the control group, and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Perceived Social Support Scale scores were higher than those of the control group (P < 0.05).

CONCLUSION

The psychological intervention program of relapse fear support which considers the individual differences between patients and expert opinions, has a good scientific and practical basis, and can be used to enhance the quality of life of patients.

Key Words: Cervical cancer; Recurrence; Fear; Support; Psychological intervention

Core Tip: To establish a psychological intervention program for fear of cervical cancer recurrence and ease patients’ postoperative psychological stress, 13 experts revised the draft through literature review and group discussion, with pre-experiments for further refinement. The program was then tested on 80 cervical cancer patients. Results showed high expert authority and consistency. The study group exhibited lower fear of recurrence and psychological distress scores, and higher quality of life and social support scores than the control group. This program, considering individual differences and expert advice, is scientifically and practically sound for improving patients’ quality of life.

INTRODUCTION

Cervical cancer is a malignant tumor occurring in the cervix[1]. Surgical resection and comprehensive treatment can achieve a certain intervention effect, and the 5-year survival rate of early-stage and late-stage patients is 80%-90% and 50%-60%, respectively[2]. However, many factors influence the recurrence rate of cervical cancer following diagnosis and treatment. Some studies have demonstrated that approximately 30%-50% of patients will have tumor recurrence or metastasis after the initial treatment[3]. Moreover, the long-term survival rate of patients with recurrence and metastasis is only 10%-20%, causing a significant impact on the physical and mental health of patients. A common psychological problem in postoperative patients with cervical cancer is fear of recurrence, causing long-term negative impacts on their quality of life and mental health and increasing the risk of social avoidance, suicide, and other adverse events[4,5].

Previous studies have highlighted the high prevalence and clinical significance of fear of cancer recurrence (FCR) among cancer survivors. For instance, research by Simard and Savard[6] in 2009 indicated that FCR is one of the most frequently reported unmet needs. While several interventions have been developed to address FCR in breast cancer and other common malignancies, there is a relative scarcity of structured, evidence-based interventions specifically tailored for cervical cancer patients. Most existing studies focus on general psychological support rather than targeted interventions for FCR[7,8]. This gap underscores the necessity to develop a specialized intervention program that addresses the unique psychological and emotional challenges faced by cervical cancer survivors.

The fear of progression (FoP) theory provides a robust theoretical framework for understanding FCR, emphasizing the cognitive and emotional processes through which patients perceive and respond to the threat of disease progression[9]. According to this theory, patients’ fear arises from the conflict between the desire to maintain health and the perceived threat of recurrence, leading to significant psychological distress. Supportive psychological interventions grounded in the FoP theory aim to address these cognitive-emotional conflicts by enhancing patients’ coping strategies, promoting emotional regulation, and restructuring maladaptive thoughts related to recurrence. Therefore, devising a supportive psychological intervention system for fear of recurrence in patients with cervical cancer based on the FoP theoretical framework to assist them in reducing their fear and improving their psychological resilience is of great clinical significance for promoting disease recovery and improving the overall prognosis. Innovatively, this study developed a comprehensive recurrence fear supportive psychological intervention program through a rigorous process including literature reviews, group discussions, and expert correspondence. Unlike previous approaches, this program is specifically designed for cervical cancer patients, incorporates multi-disciplinary strategies, and is structured to be implemented in a phased and graded manner, thereby addressing a critical gap in existing supportive care and offering a tailored solution to mitigate FCR in this patient population.

MATERIALS AND METHODS

General information

Qualitative research group: Nine team members were included comprising three men and six women; age range 25 years to 51 years, with a mean age of 33.13 ± 5.27 years. Among them, two deputy chief nurse practitioners, two chief nurse practitioners, two nurse practitioners, one deputy chief physician, one reproductive expert, and one psychology expert were responsible for the preliminary research, including literature review, individualized interviews, preparation of expert correspondence questionnaires, and selection of correspondence experts.

Quantitative research team: Seven team members were included comprising one man and six women; age range 23 years to 50 years, with a mean age of 30.36 ± 3.47 years. Among them, there were two nurses from our hospital, including one deputy chief nurse and one supervising nurse, and five nurses from foreign hospitals, including two supervising nurses and three nurse practitioners. They were responsible for distributing and recycling the expert correspondence questionnaires and collating and analyzing the opinions given by the experts.

Psychological intervention team: Nine team members were included comprising three men and six women; age range 24-53 years, with a mean age of 32.76 ± 6.11 years. Among them, one chief nurse, two deputy chief nurses, two chief nurses, two nurse practitioners, one deputy chief physician, and one psychologist were responsible for the implementation and assessment of the psychological intervention program. The study protocol was approved by the Medical Ethics Committee of Nanjing Maternity and Child Health Hospital on July 19, 2023 (approval No. 2023KY-065-01).

Preliminary research

Literature review: The keywords such as “cervical cancer”, “psychological intervention”, “fear of recurrence”, and “support” were used to search the relevant national and international literature. The inclusion criteria were as follows: Studies that included patients with cervical cancer who fulfilled the diagnostic criteria of the Cervical Cancer Diagnostic and Treatment Guidelines; those with outcome indicators of fear of recurrence or other indicators; and studies on interventions/intervention programs for fear of recurrence. The exclusion criteria were as follows: Multiple publications of the same study and inaccessible full text.

Individualized interviews: The purposive sampling method was used to select patients who were hospitalized in the Gynecological Oncology Department of our hospital and fulfilled the inclusion and exclusion criteria for study participants. Semi-structured interviews were conducted, and the sample size was determined based on the principle of data saturation, that is, repetition of the information obtained in the interview, and the appearance of no new, repeated information even after interviewing 2-3 more respondents. Inclusion criteria were as follows: Patients with a confirmed diagnosis of cervical cancer based on the pathological criteria of the Cervical Cancer Diagnostic and Treatment Guidelines; those treated with radical cervical cancer surgery before enrolment and were aware of their condition; those who had good cognitive function and were capable of normal communication; and those who voluntarily participated in the study and signed the informed consent form. Exclusion criteria were as follows: Patients with a history of mental illness; those with severe functional impairment of major organs such as heart, liver, lung, and kidney; and those with serious complications.

Survey instrument: In-depth interviews were conducted, and the researcher selected patients with cervical cancer meeting specific criteria as the interview participants, aiming to comprehensively analyze the causes of fear of recurrence, the subjective experience of the patients, and their individual needs. An exhaustive interview outline was formulated by the researcher based on the literature review and preliminary exploration. Before the formal interview, the purpose of the study, the process, and the potential risks and benefits were explained in detail to each participant by the researcher, ensuring that the participant fully understood and voluntarily signed the informed consent form. The interview was conducted in a quiet, independent office to minimize external interference; the interview outline was used as a guide, and the patient was stimulated through open-ended questions to share their personal experiences and feelings and encourage them to narrate their experiences related to their fear of recurrence. The interview lasted until the point of saturation, that is, when the newly collected data did not provide any additional information, indicating that the goal of the interview had been achieved and the interview was naturally terminated. The interviews lasted 20-30 minutes.

Data analysis: Interview data were analyzed using the Colaizzi 7-step method to extract themes.

Group discussion

The research team combined the results of the literature search and themes refined from individualized interviews to form the first draft of a supportive psychological intervention system for fear of recurrence in patients with cervical cancer with primary, secondary, and tertiary indicators.

Implementation of “Internet + Nursing Service” synchronized health education

To ensure continuity and accessibility of health education beyond the hospital setting, the “Internet + Nursing Services” component was implemented through a structured digital framework. The specific operational procedure was as follows: (1) Platform establishment: A dedicated health education portal was created within the hospital’s existing WeChat public platform. This portal hosted all synchronized educational materials; (2) Content synchronization: All educational content delivered during in-person sessions, including the “Health Promotion Manual on Cervical Cancer Disease”, lecture PowerPoints, and recorded videos of the health lectures and Tai Chi/Ba Duan Jin guidance sessions, was digitized and uploaded to this platform; (3) Patient onboarding: Upon enrolment, patients were guided to follow the platform and were grouped into a designated chat group for the study by a dedicated research nurse; (4) Content delivery: The research nurse systematically provided the digital educational materials to the patient group according to the intervention schedule; and (5) Interactive support: Patients could access these materials at any time for review. Furthermore, they could ask questions related to the content directly in the chat group. These questions were answered within 24 hours by the assigned research nurse or the relevant specialist, ensuring timely professional support and mimicking the immediate feedback available in face-to-face settings. This approach guaranteed that the health education was not limited by time or location, providing patients with flexible, repetitive, and on-demand access to standardized educational resources, which was crucial for reinforcing learning and supporting long-term self-management.

Formation of the first draft of the program

Developing the expert questionnaire: The expert questionnaire comprised three parts: (1) A letter to the experts, describing the academic background of the study, its objectives and vision, and the structure and guidelines for completing the various types of questionnaires; (2) Intervention plan consultation form, focusing on the three levels of detailed indicators of the intervention strategy and for each indicator, the column of “optimization suggestions” and the item of “critical rating”. The critical rating is based on a five-point scale, with scores of 1-5 indicating extremely unimportant, less important, basically important, fairly important, and critically important, respectively; and the end of the table is dedicated to the areas of “Supplementary Project Proposals” and “Comprehensive Recommendations”; and (3) Basic information questionnaire for experts, including professional background, the basis of judgment, and familiarity with the subject matter. The basis of judgment for experts can be subdivided into dimensions such as practical experience, theoretical knowledge, literature review, and intuitive judgment; the degree of familiarity of experts’ self-assessment uses “large, medium, and small”, grades, with different numerical values quantified for each grade; the degree of familiarity with the content is divided into the following five levels: Unfamiliar, slightly familiar, generally familiar, more familiar, and extremely familiar.

Selection criteria for selection of correspondence: Experts engaged in clinical, nursing, psychology, and other fields related to cervical cancer; those with 10 years or more working experience; those with deputy director and above professional and technical titles; and those willing to participate in correspondence.

Expert correspondence questionnaire: The questionnaire for expert correspondence was distributed in paper form or by email with an interval of at least 2 weeks between each round. The feedback from experts was collated after the first round of expert consultation, and the indicators in the questionnaire were added, deleted, and modified to form the second round of the expert consultation questionnaire. The second round followed the same steps, and the opinions were collated until the experts’ opinions were the same. Following this, the consultation was terminated.

Statistical analysis

Data were entered using Excel and analyzed using SPSS 25.0 software. Quantitative and qualitative data were described using mean ± SD, and frequencies and composition ratios, respectively; the degree of expert positivity was measured using the effective recovery rate of the questionnaire, expert authority was expressed by the coefficient of authority (Cr), Kendall’s coefficient of coordination and the test of significance were used to express the degree of coordination of expert opinions and the degree of concentration of expert opinions was expressed by the significance assigned to the mean and coefficient of variation. Finally, a supportive psychological intervention system for fear of recurrence in patients with cervical cancer was formed. SPSS 25.0 software was used to statistically analyze data. The Shapiro-Wilk normal distribution test was used for the normality of measurement data, which indicated that it conformed to the normal distribution of measurement data. Moreover, the comparison between groups was made using the independent samples T-test; n% indicated the counting data and was tested using the χ² test. If the expectation value was < 5, it was tested by the successive corrected χ² test or the Fisher’s exact test, and P < 0.05 indicated that the differences were statistically significant.

Pre-test

A presurvey was conducted comprising 10 study participants who met the criteria of the Na-row. After the questionnaire was appropriately applied, targeted research was conducted for all the included research participants again, and the clinical evaluation indices were primarily presented in the form of questionnaires. The relevant questionnaires mainly included the general information questionnaire, the FCR Inventory (FCRI)[6], the Kessler Psychological Distress Inventory (K-10)[10], the Psychological Distress Thermometer (DT)[11], the General Hospital Anxiety and Depression Scale (HADS)[12], European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30)[13] and (EORTC QLQ-Cervical Cancer Module 24) scales, and the Chinese version of the Perceived Social Support Scale (PSSS)[14,15]. Patients with cervical cancer should be rechecked every 3 months to 6 months within 2 years after treatment. The data were collected three times at 5-7 days (T1), 3 months (T2), and 6 months postoperatively (T3).

Feedback and improvement

The feedback and opinions of patients with cervical cancer were collected and analyzed for the recurrence fear supportive psychological intervention. The patients’ satisfaction with the supportive psychological intervention, perceived degree of improvement, and impact of the intervention on their lives were determined; the effectiveness and feasibility of the intervention were discussed, and the strengths and limitations of the intervention based on the results in the practical application were analyzed. The suggestions for improvement and optimization of the problems and challenges in practical application were recorded.

To ensure the consistency and quality of the intervention implementation, fidelity checks were conducted throughout the study. All group sessions were conducted according to a standardized protocol. A random sample of 20% of the sessions was selected and evaluated by an independent research nurse using a pre-defined adherence checklist to assess the facilitator’s compliance with the protocol key components; the average adherence rate was calculated to be 95%. Regarding participant engagement, attendance records for the weekly centralized teaching lectures and “HengYi Oasis” workshops were meticulously maintained. The overall attendance rate for the study group participants was 92%. All participants completed the core one-on-one sessions and engaged with the “Internet + Nursing Services” platform, with an average log-in frequency of twice per week.

RESULTS

Expert information

The two rounds of correspondence were with the same group of experts, and the questionnaire of basic information from 13 experts is shown in Table 1.

Table 1 Basic information questionnaire for experts.

Basics		Quorum	Composition ratio (%)
Distinguishing between the sexes	Male	9	69.23
	Female	4	30.77
Work experience	10-20 years	7	53.85
	> 20 years	6	46.15
Age	30-40 years old	2	15.39
	40-50 years old	7	53.85
	> 50 years old	4	30.76
Title	High ranking	6	46.15
	Deputy high ranking	5	38.46
	Middle level (in a hierarchy)	2	15.39

Experts’ motivation

In the first round of correspondence, all 13 experts returned the questionnaires within 2 weeks. A total of 13 questionnaires were distributed, 13 (100%) were recovered, 13 (100%) were valid, and 6 (46.15%) experts made suggestions. In the second round of correspondence, 13 experts returned the questionnaires within 2 weeks, 13 were distributed, 13 (100%) were recovered, 13 (100%) were valid, and 3 (23.08%) experts made suggestions. The experts’ suggestions and revisions are shown in Table 2.

Table 2 Experts’ recommendations and revisions.

Number of communications	Suggestion		Content of the modification
Round 1	Mission approach	Innovative mission approaches	Add synchronized Tencent video live streaming on top of the regular lectures
	Forms of mission	Traditional board books are more outdated	Prepare synchronized videos for health promotion in advance
	Intervention time	Clear and harmonized timing of interventions	One-to-one opportunity for 30 minutes week by appointment
	Psychological intervention modalities	Is there some variation in psychological problems from patient to patient and is there a graded intervention?	Those at low risk are interviewed by a psychiatric nurse; those at medium risk are interviewed by a counselling clinic; and those at high risk are interviewed by a psychologist
	Psychological intervention content	Are there more factors that contribute to patients’ fear of relapse and are the intervention programs targeted?	A multidisciplinary approach is used to target interventions to patients presenting with fear of relapse through consultation
	Intervention	There are more measures to help patients relieve psychological stress, what are the specific stress reduction measures taken	Instruct patients in skills related to stress reduction tools and guide them to learn to reduce stress on their own
Round 2	Decompression schedule	What specifically are the stress reduction tools?	Stress relieving tools include stress reducing ball/stress reducing flip stick/fingertip blocks/BIG ENTER key stress reducer/ferrofluid magnetic fluid/stress reducing Rubik’s cube and so on
	Implementation	How to implement psychological interventions for postoperative cervical cancer patients?	A psychological intervention workshop for fear of relapse was set up, “HengYi Oasis”, with the head nurse of the ward as the person in charge, a nurse specialized in psychology as the leader of the team, supplemented by a nurse specialized in oncology and a nurse specialized in nutrition to provide guidance on oncology and nutrition
	Intervention	What interventions are available in addition to stress reduction tools?	Organize interventions such as positive thinking stress reduction (e.g., body scanning, meditation stress reduction method), music stress reduction (method), music sleep exercise, stress reduction breathing exercise, confiding stress reduction (method), etc.; popularize Chinese medicine meridian health exercise: Ba Duan Jin, Green Valley Wu Chun meridian exercise, clapping health exercise, taijiquan, five-step boxing, neck and shoulder exercise, tendon and muscle clapping exercises, etc.

Degree of expert authority and degree of coordination of opinions

The Cr > 0.8 in rounds 1 and 2 indicating a high degree of authority; the coefficient of expert coordination was > 0.8 and had a high degree of consistency. The tests of significance were all P < 0.05, as shown in Table 3.

Table 3 Authority coefficient and coordination factor for expert correspondence.

Number of communications	Indicator level	Number of experts	Total number of indicators	Authority coefficient	Coefficient of coordination	χ2	P value
Round 1	First class	13	3	0.811	0.821	25.134	< 0.001
	Category B	13	4	0.834	0.893	62.439	< 0.001
Round 2	First class	13	3	0.819	0.827	26.935	< 0.001
	Category B	13	4	0.856	0.889	65.341	< 0.001

Pre-test results

The relapse fear supportive psychological intervention program was identified after two rounds of expert correspondence and is shown in Table 4. Pre-tests were conducted, and the quality of life and mental health status of the study participants significantly improved after the intervention.

Table 4 Relapse fear supportive psychological intervention program.

Level 1 indicators	Secondary indicators	Goal	Forms of intervention	Time	Intervener	Location
Health education	Basic education	Produce and distribute a paper version of the “Health Promotion Manual on Cervical Cancer Disease” to give patients a basic knowledge of cervical cancer	Focused preaching	Week 1 (5-10 minutes)	Physiotherapists	Study room or ward
		Producing and distributing synchronized videos for health education on cervical cancer to enrich the form of education and stimulate patients’ interest in learning	Focused preaching	Week 1 (5-10 minutes)	Physiotherapists	Study room or ward
		Synchronizing health education content with Internet + Nursing Services to provide patients with education services that are not limited by time or location	Focused preaching	Week 1 (15-20 minutes)	Physiotherapists	Study room or ward
	Professional guidance	The department carries out weekly centralized teaching lectures and synchronized Tencent video live broadcasts, and adopts online and offline interaction to communicate and interact with patients and mobilize their learning enthusiasm	Focused preaching	Weeks 2 to 8 (15-30 minutes)	Physiotherapists	Learning room
		Provide patients with the opportunity to book a 30-minute one-on-one exchange and communication with the nurse, who is in charge of the whole process by the psychiatric nurse, giving professional assessment and guidance, and providing professional and standardized psychological interventions for the patients	Individual interventions	Weeks 1 to 8 (30 minutes)	Psychological nurse specialists	Learning room
Intervention assessment	Classified interventions	Multidisciplinary co-operation and graded interventions based on the Fear of Relapse Scale score to ensure that each patient has access to scientific and appropriate intervention management	Individual interventions	Week 1 (5-10 minutes)	Psychological intervention team	Business premises
		Low risk is intervened by psychiatric nurses, medium risk is intervened by psychological counseling clinics, and high risk is intervened by psychologists (specialists from tertiary care hospitals) in consultation, who give individualized intervention plans and put them into practice	Individual interventions	Weeks 1 to 8 (10-15 minutes)	Psychiatric nurses, physicians, psychologists	Learning room
Interventions	Forms of implementation of the intervention	Distribute stress-reducing tools (stress-reducing artefacts), such as stress-reducing ball/stress-reducing flip stick/fingertip blocks/BIG ENTER key stress-reducing artefacts/Ferrofluid magnetic fluid/stress-reducing Rubik’s cube, etc., to patients, and guide them to learn how to reduce stress on their own	Focused preaching	Week 2 (15-20 minutes)	Physiotherapists	Learning room
		Organize patients to carry out positive stress reduction (e.g., body scanning, meditation stress reduction method), music stress reduction (method), music sleep exercise, stress reduction breathing exercise, and confiding stress reduction (method) to help patients relax physically and mentally	Focused preaching	Week 3 (30-40 minutes)	Physiotherapists	Learning room
		Popularize Chinese medicine meridian health exercises, such as Ba Duan Jin, Green Valley Wu Chun meridian exercise, hand clapping health exercise, Taijiquan, Five-Step boxing, neck and shoulder exercise, and tendon slapping exercise, etc., to help the patients to maintain a healthy physical and mental state	Focused preaching	Week 4 (30-40 minutes)	Physiotherapists	Learning room

Program validation

Research participants and methods: Eighty postoperative cervical cancer patients admitted to the Gynecological Oncology Department of our hospital from January 2023 to December 2023 were selected as research participants. Inclusion criteria were as follows: Patients who fulfilled the diagnostic criteria of cervical cancer and received radical cervical cancer surgery; those aged 18-80 years, with good cognitive compliance; those with complete general information; and those who were informed and agreed to voluntarily participate in the study. Exclusion criteria were as follows: Patients with a combination of other serious organic diseases or complications; those with a history of psychological diseases; and those who had participated in other trials before enrolment or who withdrew from the study midway. Due to practical constraints in the clinical workflow during the implementation phase, a quasi-experimental design was adopted. Participants were allocated to the control (n = 40) or study group (n = 40) based on the odd-even number of their hospitalization number. The control group was treated with conventional intervention, while the study group was treated with the relapse fear supportive psychological intervention. The length of the intervention for both groups was 8 weeks.

Evaluation indices: (1) FCR[6] includes 44 entries, 0-4 points/entry, with a total score of 0-176 points. The higher score indicates a more serious fear of recurrence; (2) K-10[10] includes 10 entries, 1-5 points/entry, with a total score of 10-50 points; 10-15, 16-21, 22-29, and 30-50 points for good, average, worse, and very bad psychological state, respectively, with higher scores indicating a worse psychological state; (3) DT[11] adopts a visual scoring method to assess the pain situation, with a total score of 0-10 points, 0 points for no pain, 10 points for severe pain, and higher scores indicate more severe psychological pain; (4) HADS[12] includes two dimensions of depression and anxiety, seven entries/dimension, 0-3 points/entry. The total score of HADS is 0-21 points, with a higher score indicating more severe anxiety and depression; (5) EORTC QLQ-C30[13] consists of five dimensions: Cognitive, role, emotional, somatic, and social, with each dimension containing six entries, with a total score of 0-100, and a higher score indicating a better quality of life; and (6) PSSS[14,15] includes 12 entries, 1-7 points/entry, with a total score of 12-84, and a higher score indicating better social support.

Results

When comparing the general information between the two groups, the difference was not statistically significant (P > 0.05) (Table 5). As shown in Table 6, the FCRI, K-10, DT, and HADS scores of T2 and T3 of the study group were lower than those of the control group, while the EORTC QLQ-C30 and PSSS scores were higher than those of the control group (P < 0.05). Furthermore, the magnitudes of these differences, quantified by Cohen’s d, ranged from medium to very large, indicating not only statistical significance but also clinical relevance (Table 7).

Table 5 Comparison of general information between the two groups, n (%).

Groups	n	Age (years)	Educational level (n)		Tumor stage (n)		Treatment (n)
			Junior high school and below	High school and above	Phase I-II	Phase III	Surgeries	Surgery + combination therapy
Research group	40	51.23 ± 4.28	26 (65.00)	14 (35.00)	22 (55.00)	18 (45.00)	6 (15.00)	34 (85.00)
Control subjects	40	52.31 ± 5.16	21 (52.50)	19 (47.50)	25 (62.50)	15 (37.50)	11 (27.50)	29 (72.50)
χ2/t	-	1.019	1.290		0.464		1.867
P value	-	0.311	0.256		0.496		0.172

Table 6 Comparison of intervention effects between the two groups (score, mean ± SD).

Groups	Research group	Control subjects	t	P value
n	40	40
FCRI score
T1	131.26 ± 6.43	129.9 ± 7.11	0.845	0.401
T2	88.46 ± 5.96	93.47 ± 6.17	3.694	0.001
T3	70.13 ± 5.24	83.62 ± 6.38	10.334	0.001
K-10 rating
T1	32.43 ± 2.84	33.23 ± 3.17	1.189	0.238
T2	25.13 ± 3.34	27.58 ± 3.65	3.132	0.002
T3	15.43 ± 2.96	17.18 ± 3.37	2.468	0.016
DT score
T1	7.12 ± 0.57	7.03 ± 0.68	0.642	0.523
T2	5.01 ± 0.47	5.63 ± 0.88	3.931	0.001
T3	2.27 ± 0.39	3.11 ± 0.43	9.152	0.001
HADS score
T1	16.84 ± 1.27	17.01 ± 1.38	0.573	0.568
T2	10.25 ± 1.05	11.87 ± 1.18	6.487	0.001
T3	6.89 ± 1.33	8.01 ± 1.58	3.430	0.001
EORTC QLQ-C30 ratings
T1	54.76 ± 4.38	55.02 ± 5.13	0.244	0.808
T2	68.96 ± 4.76	64.47 ± 5.28	3.995	0.001
T3	80.26 ± 5.24	76.34 ± 5.49	3.267	0.002
PSSS score
T1	43.26 ± 3.95	42.74 ± 3.59	0.616	0.540
T2	55.69 ± 2.46	51.85 ± 3.61	5.559	0.001
T3	67.59 ± 3.81	64.13 ± 3.84	4.045	0.001

FCRI: Fear of Cancer Recurrence Inventory; K-10: Kessler Psychological Distress Inventory; DT: Distress Thermometer; HADS: Hospital Anxiety and Depression Scale; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; PSSS: Perceived Social Support Scale.

Table 7 Effect sizes (Cohen’s d) for between-group differences at T2 and T3.

	Time	Cohen’s d1
FCRI	T2	-0.84
	T3	-2.31
K-10	T2	-0.70
	T3	-0.56
DT	T2	-0.92
	T3	-2.07
HADS	T2	-1.45
	T3	-0.76
EORTC QLQ-C30	T2	0.88
	T3	0.73
PSSS	T2	1.30
	T3	0.92

¹Cohen’s d for between-group comparisons.

Negative d values indicate lower scores in the research group for Fear of Cancer Recurrence Inventory, Kessler Psychological Distress Inventory, Distress Thermometer, and Hospital Anxiety and Depression Scale. Positive d values indicate higher scores in the research group for European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 and Perceived Social Support Scale. FCRI: Fear of Cancer Recurrence Inventory; K-10: Kessler Psychological Distress Inventory; DT: Distress Thermometer; HADS: Hospital Anxiety and Depression Scale; EORTC QLQ-C30: European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30; PSSS: Perceived Social Support Scale.

DISCUSSION

The results of this study demonstrated that the recurrence fear supportive psychological intervention program led to statistically significant improvements in patients’ psychological distress and quality of life. These findings have substantial clinical significance. The statistically significant reductions in FCRI, K-10, DT, and HADS scores observed in the study group indicate a tangible alleviation of the fear of recurrence, anxiety, depression, and general psychological distress, which are paramount to the holistic recovery of cervical cancer patients. This is crucial because, as demonstrated by Simard and Savard[6] and corroborated by others[16,17], high FCR is not only a source of suffering but also correlates with poorer adherence to follow-up care and potentially worse long-term outcomes. By directly addressing this pervasive fear, our intervention contributes to breaking this negative cycle, facilitating a more positive transition to survivorship.

The benefits to patients are multifaceted. Firstly, the improvement in EORTC QLQ-C30 scores reflects an enhanced overall quality of life, encompassing better physical, emotional, and social functioning. Secondly, the increased PSSS scores suggest patients felt more supported, likely a direct result of the program’s structured social-interactive components, such as the group sessions and the ongoing digital support, which mitigate the isolation often experienced post-treatment[18]. The integration of traditional Chinese medicine (TCM) practices, such as Ba Duan Jin, offers patients practical, low-cost tools for self-management of anxiety, empowering them to actively participate in their own recovery[19,20]. This combination of psychological support, social connectivity, and mind-body training provides a comprehensive benefit package that addresses the biopsychosocial model of health.

The feasibility and potential for widespread clinical promotion of this program are supported by several key factors. First, the intervention was constructed and refined through a rigorous Delphi expert consensus process, ensuring its content validity and practical relevance. Second, the program leverages a multi-disciplinary team approach, which is increasingly the standard in modern oncology care, meaning its implementation aligns with existing clinical workflows. Crucially, incorporation of the “Internet + Nursing Services” model significantly enhances its scalability and reduces resource barriers; this digital approach allows for standardized education delivery and remote support, making it adaptable to diverse healthcare settings, including communities with limited access to specialist psychological care[21]. The positive feedback and high acceptance rates from the pre-test and study participants further underscore its practicality and patient-centeredness. Therefore, this program presents a viable, effective, and scalable model that can be widely promoted in clinical practice to improve the standard of supportive care for the growing population of cervical cancer survivors.

The development and mechanisms of this intervention can be conceptually anchored in established psychological models, such as Leventhal’s Common-Sense Model (CSM). The CSM posits that individuals form cognitive and emotional representations of their illness, which in turn guide their coping procedures and appraisal of threats. In this study, the fear of recurrence constitutes a maladaptive emotional representation. Our intervention directly targeted these representations: The health education modules aimed to reshape inaccurate cognitive representations, while the psychological and TCM stress-reduction strategies provided concrete coping procedures to manage the emotional distress and somatic arousal associated with the threat of recurrence. This theoretical lens provides a robust explanation for the intervention’s effectiveness by illustrating how it concurrently addressed the cognitive and emotional dimensions of patients’ subjective illness experience. Currently, no unified theoretical framework for supportive psychological intervention for fear of recurrence of cancer exists in China. In this study, we constructed a supportive psychological intervention program for the fear of recurrence of cervical cancer after surgery through literature reviews, group discussions, and expert correspondence. Thirteen experts conducted two rounds of consultation and formed the first draft of the program. The return rate of the questionnaires in the two rounds was 100%, and the validity rate was 100%, with a suggestion rate of 46.15% and 23.08% in the first and second rounds of consultation, respectively. The experts stated a number of effective suggestions regarding the first draft of the program. The results also demonstrated that Cr of experts in rounds 1 and 2 was > 0.8, with high authority; Cr of experts was > 0.8, with high consistency. The test of significance was P < 0.05. This indicated that the experts had a high degree of acceptance of the supportive psychological intervention program for fear of cervical cancer recurrence. The implement ability of the program was clarified through a small-scale pre-test, and further improvements and refinements were made to the intervention program. In addition to Leventhal’s CSM, the intervention’s components are also highly congruent with the principles of cognitive-behavioral therapy, which is a gold-standard approach for addressing fear-based disorders[22,23]. The intervention’s focus on psychoeducation directly targets maladaptive cognitions regarding cancer recurrence. Techniques such as stress-reduction breathing exercises, meditation, and guided self-management with stress-reducing tools constitute behavioral activation and arousal reduction strategies, which are core elements of cognitive-behavioral therapy[24].

The recurrence fear supportive psychological intervention assists patients in establishing a systematic and precise health knowledge system and correcting their false cognition of cancer recurrence; thus, reducing their unnecessary fear and anxiety. This helps to improve the patients’ mental health status and their quality of life[16,17]. A distinctive feature of this program is its integration of TCM theories and therapies, which offers a holistic approach to alleviating fear and anxiety. In TCM theory, emotions are closely linked to the function of the Zang-fu organs. Fear and anxiety are believed to deplete Qi and adversely affect the heart, kidneys, and liver. The intervention incorporated TCM meridian health exercises, such as Ba Duan Jin and Tai Chi Chuan, which are designed to regulate the flow of Qi and blood, strengthen the body, and harmonize the mind and emotions. These mindful-body practices help to calm the Shen, reduce emotional stress, and improve overall energy balance, providing patients with practical tools for self-management of their fear and contributing to a sustained positive psychological state. In this study, the recurrence fear supportive psychological intervention was used in postoperative cervical cancer patients, and the results demonstrated that the FCRI, K-10, DT, and HADS scores of T2 and T3 in the study group were lower than those in the control group. Thus, this intervention program can promote the recovery of patients’ postoperative mental health status. Lin and Sun[18] demonstrated that the implementation of supportive psychological intervention for patients with cervical cancer can improve psychological resilience and their mental health status, similar to some of the findings in this study. The experts were invited to make disciplinary suggestions during the program construction to further refine and improve the psychological intervention program, further improving the systematic, scientific, and effective nature of the overall program[19,21]. In the process of intervention, the routine education manuals and health lectures, along with the production and distribution of synchronous health education videos, the use of “Internet + Nursing Services” to carry out nursing, synchronous health education and live video broadcasts was used to enrich the online and offline interactive methods. Thus, this could effectively stimulate the patients’ enthusiasm for learning, mobilize the patients’ subjective initiative to learn health knowledge, and further improve health cognition. It is important to improve fear, anxiety, and other adverse emotions to further improve health cognition[20,25]. Simultaneously, patients can have a 30-minute one-on-one communication with the psychiatric nurses by appointment every week, which can provide patients with professional and appropriate psychological guidance and have a positive effect on alleviating their negative emotions. Consequently, there was a more significant improvement in the mental health status of postoperative cervical cancer patients who received the recurrence fear supportive psychological intervention than in those receiving conventional interventions. The results of this study also demonstrated that the EORTC QLQ-C30 and PSSS scores of T2 and T3 in the study group were higher than those in the control group. This indicates that relapse fear supportive psychological intervention improves patients’ quality of life and social support. Thus, by distributing and instructing patients to learn the application of stress-reducing tools, popularizing the Chinese medicine meridian health exercise, and instructing patients to perform positive and musical stress reduction, this analysis can assist patients in maintaining a more stable and normal emotional state, which is conducive to the formation of a benign cycle. This can improve their postoperative quality of life and social support[26,27].

Limitations and future directions

Despite promising findings, this study has several limitations. First, the quasi-experimental design with allocation by hospitalization number rather than full randomization may introduce selection bias and restrict causal inference regarding efficacy. Second, the modest sample size, although adequate for primary outcomes, limited statistical power to detect subtler effects or conduct subgroup analyses. Third, the 6-month follow-up period may be insufficient to assess long-term sustainability of benefits, particularly FCR, which often persists chronically. Furthermore, reliance solely on patient-reported outcomes risks self-report bias. Future studies could incorporate objective biomarkers or clinician-rated measures to complement patient-reported outcomes. Although multiple comparisons were conducted without correction to avoid inflating type II error, the risk of type I error remains. However, consistent significance (P < 0.05) and parallel improvements across scales enhanced the credibility of the results. Additionally, while not a major issue here, missing data were not handled by intention-to-treat, which should be adopted in larger trials with higher attrition risk. Finally, although attendance was reported, dose-response relationships were not examined. Future research should analyze how session attendance influences outcomes. Effect sizes were also not reported; future work will include them to clarify the clinical significance of improvements alongside statistical results.

CONCLUSION

A more satisfactory intervention effect can be achieved in cervical cancer using the recurrence fear supportive psychological intervention, which can improve the emotional and psychological state of patients, quality of life and social support, and provide a reference for the selection of postoperative interventions.