Abstract
This study aimed to evaluate the clinical effects of combining focused psychological care with enteral nutrition in colorectal cancer (CRC) patients undergoing chemotherapy. Specifically, it assessed the impact on anxiety, depression, psychological resilience, nutritional status, complication rates, and quality of life. A retrospective cohort design was employed, involving 157 CRC patients who received first-time chemotherapy at the oncology department between May 2019 and October 2024. The patients were divided into 2 groups: an observation group (80 patients) receiving focused psychological care combined with enteral nutrition, and a control group (77 patients) receiving routine nursing care. Anxiety and depression were measured using the self-assessment anxiety scale and the self-assessment depression scale, while psychological resilience was assessed using the Connor–Davidson resilience scale (CD-RISC). Nutritional status was evaluated using the subjective global assessment, body mass index, serum albumin (ALB), prealbumin (PA), total protein, and triceps skinfold thickness. Complication rates and quality of life were measured using the EORTC QLQ-C30 scale. Statistical analysis revealed no significant differences between the groups in terms of demographic or disease characteristics. Following the intervention, the observation group showed significantly lower self-assessment anxiety scale and self-assessment depression scale scores (P <.001), as well as substantial improvements in psychological resilience (P <.001). Nutritional indices, including body mass index, subjective global assessment, PA, total protein, and ALB, were significantly better in the observation group compared to the control group (P <.05). Additionally, the incidence of complications such as nausea, vomiting, loss of appetite, bloating, diarrhea, and phlebitis was significantly lower in the observation group (P <.05). Furthermore, quality of life outcomes, including emotional and functional well-being, were notably improved in the observation group compared to the control group (P <.05). These findings suggest that the combination of focused psychological care and enteral nutrition effectively improves anxiety, depression, psychological resilience, and nutritional status in CRC patients undergoing chemotherapy. This approach also reduces complication rates and enhances overall quality of life, underscoring its significant clinical value. It is recommended that this comprehensive nursing model be integrated into clinical practice to improve treatment adherence and enhance patient quality of life.
Keywords: chemotherapy, colorectal cancer, enteral nutrition, focused psychological care, psychological resilience
1. Introduction
Colorectal cancer (CRC) is one of the most prevalent and deadly malignancies worldwide, accounting for a significant proportion of cancer-related deaths.[1–3] According to the Global Agency for Research on Cancer (GLOBOCAN), the incidence and mortality rates of CRC are rising globally, particularly in developed and certain low- and middle-income countries.[4,5] Although advances in early screening and therapeutic interventions have improved the 5-year survival rate for CRC, chemotherapy remains a cornerstone of treatment, especially for patients with intermediate to advanced stages.[6,7] However, chemotherapy, despite its survival benefits, is associated with numerous side effects that can negatively impact both physical and psychological health, complicating treatment adherence and overall outcomes.[8]
Research indicates that patients undergoing chemotherapy for CRC frequently experience psychological challenges, such as anxiety and depression, which can impair psychological resilience and exacerbate physical discomfort and treatment complications.[9] In addition, chemotherapy can lead to malnutrition, further weakening the body and impairing immune function, which may, in turn, affect the efficacy of treatment and recovery.[10] These interconnected issues – psychological distress and malnutrition – highlight the urgent need for interventions that address both the psychological and physical aspects of patient care.
The combination of focused psychological care and enteral nutrition represents an integrative approach to address these challenges simultaneously. Focused psychological care, a holistic nursing intervention, combines psychological strategies such as cognitive-behavioral therapy (CBT), emotional support, and relaxation techniques, with an emphasis on improving emotional and mental well-being.[11] This approach has been shown to alleviate anxiety, depression, and stress, thereby enhancing psychological resilience and contributing to better overall treatment outcomes.[12] On the other hand, enteral nutrition is a well-established therapeutic intervention in CRC chemotherapy, which not only supports nutritional recovery but also strengthens immune function and improves tolerance to treatment.[13,14]
While both psychological care and nutritional support have been studied individually in cancer care, limited research has explored their combined impact, especially during chemotherapy for CRC patients. The existing literature typically addresses these interventions separately, without examining their potential synergistic effects on overall patient outcomes. This gap underscores the need for research that integrates these 2 aspects of care. Thus, this study aims to evaluate the clinical effects of combining focused psychological care with enteral nutrition in CRC patients undergoing chemotherapy. Specifically, the study will assess the impact on anxiety, depression, psychological resilience, nutritional status, complication rates, and quality of life. By investigating the combined benefits of these interventions, this study provides a scientific foundation for optimizing comprehensive nursing care strategies in the treatment of CRC.
2. Materials and methods
2.1. Study design
This study was designed as a retrospective cohort analysis to evaluate the effectiveness of the focused psychological care nursing model during chemotherapy for CRC patients. The study was approved by the Affiliated Provincial Hospital of Fuzhou University’s ethics committee and adhered to privacy protection regulations. No patient interventions were involved, as the study relied on the collection and analysis of electronic medical records and treatment histories. Given the retrospective nature of the study, informed consent was waived by the ethics committees. All data were anonymized and de-identified, and were solely used for academic publication purposes.
2.2. Study population
The study population consisted of CRC patients admitted to the oncology department from May 2019 to October 2024. All patients had a confirmed pathological diagnosis, met the indications for chemotherapy, and were undergoing chemotherapy for the first time. Based on the type of care model received, patients were divided into 2 groups: the observation group (focused psychological care) and the control group (conventional care). A total of 157 patients were included, with 77 in the control group and 80 in the observation group.
Inclusion criteria: diagnosis of CRC: patients diagnosed with colorectal cancer (CRC) through pathological examination (e.g., biopsy) or imaging methods (e.g., CT, MRI). Chemotherapy Indication: Patients who have indications for chemotherapy, specifically those with CRC at intermediate to advanced stages requiring chemotherapy. First-time Chemotherapy: Patients who are receiving chemotherapy for the first time. Enteral nutrition eligibility: All patients were eligible for and received enteral nutrition support to address any nutritional deficiencies during chemotherapy. Psychiatric and cognitive status: patients with no history of severe psychiatric illness (e.g., schizophrenia, bipolar disorder) or cognitive impairments that would interfere with participation or cooperation with treatment. Age criteria: patients aged 18 to 75 years, as this age group was chosen to focus on the adult population while excluding extremes that could complicate outcome assessments.
Exclusion criteria: severe psychiatric disorders: patients with a history of severe psychiatric conditions, such as schizophrenia or bipolar disorder, which could interfere with treatment adherence or the psychological assessments. Substance abuse: patients with a history of drug or alcohol dependence, which might affect compliance with treatment or confound results. Cognitive impairment: patients who are unable to communicate or understand the study protocol due to significant cognitive impairments. Concurrent malignancies: patients with other concurrent malignancies that could complicate the assessment of CRC-specific outcomes. Severe comorbidities: patients with poorly controlled comorbid conditions such as diabetes or severe gastrointestinal diseases (e.g., intestinal obstruction, inflammatory bowel disease) that could interfere with chemotherapy or nutritional support. Significant organ dysfunction: patients with significant organ dysfunction (e.g., renal, hepatic, or cardiac failure), which could affect the tolerability of chemotherapy or the effectiveness of enteral nutrition. Noncompliance risk: patients who may have difficulties complying with the chemotherapy regimen, nutritional support, or follow-up assessments due to socio-economic or logistical factors. Pregnancy or breastfeeding: female patients who are pregnant or breastfeeding were excluded due to potential risks to the fetus or infant from chemotherapy or enteral nutrition.
2.3. Models of care
The intervention includes face-to-face psychological sessions, telephone follow-ups, and online support, all of which are standardized according to a defined protocol. A combination of CBT, emotional support, relaxation techniques, and other interventions is used. The intervention is delivered by trained psychological nurses or clinical psychologists who have received specific training in psychological care for cancer patients. The intervention consists of 3 focused sessions per chemotherapy cycle and 2 follow-up visits, with the frequency and methods adapted according to the patient’s condition. The psychological care process is conducted as follows:
2.3.1. Standardization
The intervention follows a structured framework, developed based on established psychological care guidelines for cancer patients, such as the NCCN Distress Management Guidelines and ESPEN guidelines for nutritional support. This framework ensures consistency and quality in the delivery of psychological care across all participants.
2.3.2. Personnel and training
The intervention is delivered by trained healthcare professionals, including certified psychological nurses and clinical psychologists. These professionals undergo specialized training in managing psychological distress in cancer patients, particularly in applying CBT, relaxation techniques, and providing emotional support. The training includes modules on the psychological effects of chemotherapy, coping mechanisms, and effective communication skills for supporting patients with cancer.
2.3.3. Frequency and adaptation
The intervention consists of 3 focused psychological sessions and 2 follow-up visits for each chemotherapy cycle. The frequency and content of these sessions are adapted based on individual patient needs and their psychological status. Adjustments are made throughout the treatment process to ensure that the interventions are relevant to the patient’s condition at each stage of chemotherapy. The steps are as follows:
2.3.3.1. First chemotherapy cycle
Initial assessment and relationship building (Day 1–2)
Establish trust, assess the patient’s psychological status, develop a personalized care plan, and explain typical psychological responses to chemotherapy.
CBT and emotional diversion (Day 3–5)
Use CBT techniques to help patients adjust negative thought patterns and teach emotional diversion. Additionally, relaxation techniques such as deep breathing and meditation are introduced.
Emotional support and psychological counseling (Day 10–12)
Monitor emotional changes, provide emotional support, and encourage patients to express their feelings.
Relaxation training and emotional support (Day 17–19)
Continue relaxation techniques to manage discomfort and stress, along with ongoing emotional support.
2.3.3.2. Second chemotherapy cycle
Cognitive reconstruction and emotional regulation (Day 24–26)
Reinforce cognitive restructuring to correct negative thinking patterns and improve emotional regulation.
Emotional support and symptom relief (Day 30–32)
Assess emotional state, offer emotional support, and address distress related to chemotherapy side effects.
Positive psychological intervention and psychological preparation (Day 37–39)
Focus on positive psychological strategies to prepare patients for recovery post-chemotherapy and boost self-confidence.
2.3.3.3. Third chemotherapy cycle
Reinforcement of Coping Strategies and Emotional Management (Day 50–52)
Strengthen coping mechanisms to help patients manage emotions and stress as chemotherapy concludes.
Summary and psychological support (Day 58–60)
Review emotional progress and provide ongoing psychological support, including health guidance for the recovery phase.
Routine nursing care includes standardized, fundamental nursing interventions aimed at stabilizing the patient’s physical condition and ensuring the smooth continuation of treatment. It focuses on physiological care and prioritizes the patient’s phys¬ical health. Routine nursing care encompasses the following components:
2.3.3.4. Basic nursing care
Personal hygiene assistance
Helping patients with daily activities such as bathing, oral care, and grooming to maintain cleanliness and comfort, especially in a weakened state during chemotherapy.
Safe environment maintenance
Ensuring that the patient’s environment is safe, including proper positioning to prevent falls and the maintenance of infection control standards to reduce the risk of hospital-acquired infections.
Medication management
Assisting patients with their chemotherapy regimens and ensuring that medications, including anti-nausea and pain relief drugs, are administered on time and according to protocol. Clear guidance is provided regarding oral medications and intravenous therapies.
Activity of daily living support
Helping with mobility issues, ensuring patients receive adequate rest, and assisting with feeding when needed, given the potential impact of chemotherapy on appetite and energy levels.
2.3.3.5. Pain management
Pain assessment and intervention
Evaluating and managing chemotherapy-related pain using pharmacological (e.g., analgesics) and non-pharmacological methods (e.g., relaxation techniques, positioning, or mild massage). Pain control is individualized based on the patient’s needs, with regular assessment of pain levels and adjustment of interventions.
Symptom control
Besides pain, routine care includes the management of other symptoms that chemotherapy patients often face, such as nausea, vomiting, and fatigue. The nursing staff helps with the application of remedies such as antiemetics, hydration, and nutritional adjustments to minimize side effects.
2.3.3.6. Chemotherapy side effect management
Chemotherapy-induced nausea and vomiting
Routine care includes administering antiemetic medications according to protocol to prevent or reduce the severity of nausea and vomiting, one of the most common and debilitating side effects of chemotherapy.
Loss of appetite
Nurses ensure that the patient’s nutritional needs are addressed, even when appetite is poor. They may recommend small, frequent meals, provide nutritional supplements, and suggest strategies to encourage fluid intake to prevent dehydration.
Fatigue and weakness
Nurses help manage chemotherapy-induced fatigue by educating patients on pacing their activities, promoting light physical activities, and ensuring appropriate rest periods.
2.3.3.7. Disease monitoring and observation
Vital signs monitoring
Regular observation and recording of vital signs (e.g., temperature, blood pressure, heart rate) to identify any early signs of complications. Specific attention is given to monitoring for symptoms of infection, particularly in immunocompromised patients.
Nutritional and immune status
Routine nursing includes monitoring the patient’s nutritional intake and addressing nutritional deficiencies, with close attention to serum albumin and prealbumin (PA) levels, as well as weight changes. Nurses observe changes in immune function as chemotherapy can often lead to neutropenia and increased infection risk.
Early detection of complications
Nurses are trained to identify and respond to potential chemotherapy-related complications, such as phlebitis at intravenous sites, gastrointestinal issues, or bleeding tendencies due to myelosuppression. They conduct regular assessments to detect these complications early and initiate prompt treatment when necessary.
2.3.3.8. Educational support
Patient education
Routine care involves educating patients about their disease and treatment plan. Nurses provide information on the importance of adhering to the chemotherapy schedule, the potential side effects, and how to manage them. This includes guidance on avoiding infections, recognizing the signs of complications, and understanding the role of nutrition during treatment.
Dietary guidance
Nurses provide advice on maintaining a balanced diet during chemotherapy, recommending foods that are gentle on the stomach and that help maintain adequate nutrition despite chemotherapy-related side effects. If patients are receiving enteral nutrition, nurses monitor the progress and ensure appropriate delivery.
2.3.3.9. Psychosocial support (within routine care)
Although routine care is not specifically psychological, nurses in the control group provide basic emotional support and comfort. They may offer patients an empathetic ear, ensure they feel heard during routine visits, and provide a safe environment to express concerns. However, more structured psychological support (such as CBT) is not included as part of this care model.
2.4. Observation indicators
Assessments were conducted before chemotherapy and after the completion of 3 chemotherapy cycles.
(1) Psychological status assessment: the self-assessment anxiety scale (SAS) and self-assessment depression scale (SDS) were used to assess the levels of anxiety and depression in patients before and after chemotherapy. Higher scores indicated more severe symptoms.
(2) Psychological resilience assessment: the Connor–Davidson resilience scale (CD-RISC), developed by Davidson et al, was employed to evaluate psychological resilience. This 25-item scale is widely used to assess an individual’s ability to cope with and adapt to stress and adversity. Higher scores indicate better stress management and greater resilience.
(3) Nutritional status assessment: the subjective global assessment (SGA) was used to evaluate the nutritional status of both groups after the intervention, with scores ranging from 0 to 25. A lower score indicates better nutritional status, while a higher score reflects more severe malnutrition. Additionally, objective measures, including serum albumin (ALB), serum PA, serum total protein (TP), body mass index (BMI), and triceps skinfold thickness, were used to compare nutritional status between the 2 groups.
(4) Complications comparison: the incidence of gastrointestinal reactions, phlebitis, neurotoxicity, and myelosuppression during treatment was recorded and compared between the 2 groups.
(5) Quality of life assessment: the EORTC QLQ-C30 scale was used to assess the quality of life in both groups of patients.
2.5. Statistical analysis
All data analyses were conducted using the IBM SPSS Statistics 25 software package. Continuous data were expressed as mean ± standard deviation (X ± SD) for normally distributed data, while non-normally distributed data were expressed as median (interquartile range, IQR). Categorical data were presented as frequency (n) and percentage (%). Normality of the continuous variables was assessed using the Shapiro–Wilk test. For normally distributed data, comparisons were made using either a t-test or 1-way analysis of variance (ANOVA). For non-normally distributed data, nonparametric tests (such as the Mann–Whitney U test or Kruskal–Wallis test) were applied. Correlation analysis between categorical variables was performed using the chi-square test. To account for potential confounding factors, logistic regression was used to adjust for variables that could influence the outcomes, including cancer stage, treatment duration, comorbidities (such as hypertension, diabetes), baseline nutritional status, and psychological state. These factors were selected based on their potential impact on the treatment outcomes and to reduce bias in the analysis.
A power calculation was conducted using G*Power software to determine the necessary sample size for detecting significant effects. The required sample size was based on the expected effect sizes and desired statistical power, ensuring that the study had sufficient power to detect meaningful differences between groups. Missing data were minimal (<5%), and multiple imputation methods were applied to handle any missing values. This approach helps to preserve statistical power and reduce potential bias in the analysis. In case of multiple comparisons, the P-value was corrected using the Bonferroni correction method to reduce the risk of Type I error. The level of statistical significance was set at P < .05.
3. Results
3.1. Demographic characteristics
Table 1 presents a comparison of demographic characteristics between the control and observation groups. No significant differences were observed between the 2 groups regarding age, gender, marital status, education, occupation, average monthly household income, or insurance payment method (all P > .05).
Table 1.
Comparison of demographic characteristics between the control group and observation group (X ± SD, n/%).
| Variables | Control group (N = 77) | Observation group (N = 80) | t/F/χ² | P-value |
|---|---|---|---|---|
| Age (year) | ||||
| >60 | 44 (57.14%) | 47 (58.75%) | 0.046 | .830 |
| ≤60 | 33 (42.86%) | 33 (41.25%) | ||
| Gender | ||||
| Male | 46 (59.74%) | 48 (60.00%) | 0.003 | .950 |
| Female | 31 (40.26%) | 32 (40.00%) | ||
| Marital status | ||||
| Unmarried | 4 (5.19%) | 4 (5.00%) | 0.363 | .550 |
| Married | 54 (70.13%) | 58 (72.50%) | ||
| Divorced | 10 (12.99%) | 8 (10.00%) | ||
| Widowed | 9 (11.69%) | 10 (12.50%) | ||
| Cultural levels | ||||
| Primary school or below | 30 (38.96%) | 30 (37.50%) | 0.439 | .960 |
| Junior high school | 10 (12.99%) | 12 (15.00%) | ||
| Senior high school | 18 (23.38%) | 16 (20.00%) | ||
| University or above | 19 (24.68%) | 22 (27.50%) | ||
| Occupation | ||||
| Farmers or migrant workers | 28 (36.36%) | 30 (37.50%) | 0.261 | .880 |
| Company employees | 16 (20.78%) | 17 (21.25%) | ||
| Civil servants or public institution employees | 11 (14.29%) | 11 (13.75%) | ||
| Freelancers | 19 (24.68%) | 20 (25.00%) | ||
| Unemployed or retired | 3 (3.90%) | 2 (2.50%) | ||
| Average monthly household income | ||||
| <5000 CNY/mo | 20 (25.97%) | 21 (26.25%) | 0.032 | .980 |
| 5000–10,000 CNY/mo | 48 (62.34%) | 49 (61.25%) | ||
| 10,000 CNY/mo | 9 (11.69%) | 10 (12.50%) | ||
| Insurance payment method | ||||
| Self-paid | 8 (10.39%) | 7 (8.75%) | 0.380 | .820 |
| Urban employee health insurance | 36 (46.75%) | 35 (43.75%) | ||
| Rural and urban resident health insurance | 33 (42.86%) | 38 (47.50%) | ||
SD = standard deviation.
3.2. Disease characteristics
Table 2 compares the disease characteristics between the 2 groups. No significant differences were found in terms of tumor primary site, tumor size, histological type, clinical stage, or CEA level (all P > .05). Additionally, the prevalence of hypertension, smoking, hyperlipidemia, and alcohol consumption was similar between the 2 groups (all P > .05).
Table 2.
Comparison of disease characteristics between the control group and observation group (n/%).
| Variables | Control group (N = 77) | Observation group (N = 80) | F/χ² | P-value |
|---|---|---|---|---|
| Primary site | ||||
| Right colon | 15 (19.48%) | 16 (20.00%) | 0.406 | .982 |
| Transverse colon | 3 (3.90%) | 2 (2.50%) | ||
| Left colon | 25 (32.47%) | 28 (35.00%) | ||
| Sigmoid colon | 19 (24.68%) | 18 (22.50%) | ||
| Rectum | 15 (19.48%) | 16 (20.00%) | ||
| Tumor size (cm) | ||||
| <4.6 | 31 (40.26%) | 34 (42.50%) | 0.272 | .874 |
| 4.6–6.9 | 29 (37.66%) | 31 (38.75%) | ||
| >6.9 | 17 (22.08%) | 15 (18.75%) | ||
| Histology | ||||
| Adenocarcinoma | 66 (85.71%) | 68 (85.00%) | 0.522 | .893 |
| Mucinous adenocarcinoma | 7 (9.09%) | 6 (7.50%) | ||
| Signet ring cell carcinoma | 3 (3.90%) | 4 (5.00%) | ||
| others | 1 (1.30%) | 2 (2.50%) | ||
| Clinical staging | ||||
| II | 58 (75.32%) | 63 (78.75%) | 0.273 | .873 |
| III | 13 (16.88%) | 12 (15.00%) | ||
| IV | 6 (7.79%) | 5 (6.25%) | ||
| CEA level | ||||
| Negative | 33 (42.86%) | 36 (45.00%) | 0.073 | .794 |
| Positive | 44 (57.14%) | 44 (55.00%) | ||
| Medical history | ||||
| Hypertension | 26 (33.77%) | 29 (36.25%) | 0.108 | .742 |
| Smoker | 20 (25.97%) | 19 (23.75%) | 0.097 | .765 |
| Dyslipidaemia | 43 (55.84%) | 46 (57.50%) | 0.044 | .842 |
| Drink | 13 (16.88%) | 12 (15.00%) | 0.098 | .751 |
CEA = carcinoembryonic antigen.
3.3. Anxiety and depression
Table 3 presents the anxiety (SAS) and depression (SDS) scores for both groups before and after care. Both groups experienced a significant reduction in anxiety and depression scores following the intervention (both P < .001). The improvement was more pronounced in the observation group, with SAS scores (P < .001) and SDS scores (P < .001) showing a greater decrease compared to the control group.
Table 3.
Anxiety and depression assessment before and after nursing care in both groups (X ± SD).
| Group | SAS | SDS | ||||||
|---|---|---|---|---|---|---|---|---|
| Before | Post | t | P-value | Before | Post | t | P-value | |
| Control group (N = 77) | 64.52 ± 16.72 | 48.54 ± 12.04 | 5.562 | <.001 | 55.47 ± 17.24 | 46.49 ± 11.48 | 4.584 | <.001 |
| Observation group (N = 80) | 66.08 ± 15.46 | 36.27 ± 16.23 | 7.813 | <.001 | 56.84 ± 16.34 | 40.18 ± 13.38 | 6.087 | <.001 |
| t | 0.607 | 5.396 | – | – | 0.510 | 3.174 | – | – |
| P-value | .544 | <.001 | – | – | .611 | .002 | – | – |
SAS = self-assessment anxiety scale, SD = standard deviation, SDS = self-assessment depression scale.
3.4. Psychological resilience
Table 4 compares the psychological resilience scores between the 2 groups before and after care. Both groups showed significant improvements in overall psychological resilience following the intervention. However, the observation group demonstrated significantly greater improvements than the control group in resilience (P = .002), optimism (P <.001), and total psychological resilience (P <.001).
Table 4.
Comparison of psychological resilience score before and after nursing care between the 2 groups (X ± SD).
| Control group (N = 77) | Observation group (N = 80) | t | P-value | |
|---|---|---|---|---|
| Before | ||||
| Hardiness | 28.56 ± 9.98 | 26.58 ± 11.08 | 1.182 | .245 |
| Self-reliance | 19.81 ± 5.51 | 20.15 ± 6.07 | 0.375 | .718 |
| Optimism | 6.16 ± 2.24 | 5.81 ± 1.38 | 1.173 | .244 |
| Total resilience | 51.84 ± 15.26 | 50.53 ± 17.09 | 0.517 | .613 |
| Post | ||||
| Hardiness | 30.73 ± 6.88 | 33.85 ± 5.18 | 3.248 | .002 |
| Self-reliance | 23.82 ± 4.28 | 24.23 ± 8.19 | 0.395 | .694 |
| Optimism | 15.79 ± 4.18 | 20.52 ± 6.19 | 5.635 | <.001 |
| Total resilience | 69.27 ± 9.56 | 76.89 ± 12.17 | 4.376 | <.001 |
SD = standard deviation.
3.5. Nutritional status
Table 5 compares the nutritional status of the 2 groups before and after care. Prior to the intervention, there were no significant differences between the groups in BMI, SGA, PA, serum TP, ALB, or triceps skinfold thickness (all P >.05). After the intervention, the observation group showed significant improvements in BMI (P = .004), SGA score (P <.001), PA (P <.001), serum TP (P = .013), and ALB (P = .014), while no significant changes were observed in the control group (all P >.05).
Table 5.
Comparison of nutritional status before and after nursing care between the 2 groups (X ± SD).
| Control group (N = 77) | Observation group (N = 80) | t | P-value | |
|---|---|---|---|---|
| Before | ||||
| BMI (kg/m²) | 22.13 ± 1.86 | 22.29 ± 3.24 | 0.378 | .706 |
| SGA | 12.68 ± 2.12 | 11.86 ± 3.09 | 1.932 | .055 |
| Serum prealbumin (PA/[mg·L−1]) | 173.56 ± 12.57 | 175.08 ± 14.19 | 0.709 | .479 |
| Serum total protein (TP/[g·L−1]) | 67.88 ± 4.39 | 68.18 ± 5.26 | 0.387 | .699 |
| Serum albumin (ALB/[g·L−1]) | 42.73 ± 3.65 | 43.08 ± 3.82 | 0.587 | .558 |
| triceps skinfold thickness (mm) | 13.98 ± 2.11 | 14.03 ± 2.56 | 0.133 | .894 |
| Post | ||||
| BMI (kg/m2) | 21.04 ± 1.56 | 22.01 ± 2.48 | 2.921 | .004 |
| SGA | 9.85 ± 2.18 | 8.13 ± 1.96 | 8.869 | <.001 |
| Serum prealbumin (PA/[mg·L−1]) | 156.63 ± 13.74 | 165.88 ± 11.27 | 4.62 | <.001 |
| Serum total protein (TP/[g·L−1]) | 64.53 ± 3.19 | 66.05 ± 4.26 | 2.523 | .013 |
| Serum albumin (ALB/[g·L−1]) | 39.63 ± 3.45 | 41.13 ± 4.05 | 2.494 | .014 |
| Triceps skinfold thickness (mm) | 13.01 ± 1.63 | 13.24 ± 1.96 | 0.798 | .426 |
ALB = serum albumin, BMI = body mass index, PA = prealbumin, SGA = subjective global assessment, SD = standard deviation, TP = total protein.
3.6. Complications
Table 6 presents the complications observed in both groups after care. The incidence of nausea and vomiting (χ² = 7.95, P = .005), loss of appetite (χ² = 7.30, P = .007), bloating and diarrhea (χ² = 4.59, P = .032), and phlebitis (χ² = 4.28, P = .037) was significantly lower in the observation group compared to the control group. The incidence of neurotoxicity was also lower in the observation group (21.25% vs 33.77%), though the difference did not reach statistical significance (P = .080).
Table 6.
Comparison of complications after nursing care between the 2 groups (n/%).
| Control group (N = 77) | Observation group (N = 80) | χ² | P-value | |
|---|---|---|---|---|
| Nausea and vomiting | 62 (80.52%) | 48 (60.00%) | 7.95 | .005 |
| Loss of appetite | 63 (81.82%) | 50 (62.50%) | 7.3 | .007 |
| Abdominal distension and diarrhea | 43 (55.84%) | 31 (38.75%) | 4.59 | .032 |
| Oral ulcers | 43 (55.84%) | 36 (45.00%) | 1.89 | .170 |
| Hair loss | 66 (85.71%) | 66 (82.50%) | 0.27 | .600 |
| Phlebitis | 24 (31.17%) | 11 (13.75%) | 4.28 | .037 |
| Neurotoxicity | 26 (33.77%) | 17 (21.25%) | 3.08 | .080 |
| Myelosuppression | 20 (25.97%) | 16 (20.00%) | 0.76 | .380 |
3.7. Quality of life
Table 7 compares the quality of life between the 2 groups before and after care. The observation group showed significantly greater improvements than the control group in emotional well-being (t = 2.665, P = .009), functional well-being (t = 2.210, P = .029), and overall quality of life scores (t = 6.660, P < .001). However, there were no significant differences between the groups in physical well-being, social well-being, or CRC-specific subscales (all P >.05).
Table 7.
Comparison of quality of life before and after nursing care between the 2 groups (X ± SD).
| Control group (N = 77) | Observation group (N = 80) | t | P-value | |
|---|---|---|---|---|
| Before | ||||
| Physiological well-being | 14.56 ± 4.15 | 14.25 ± 4.19 | 0.471 | .645 |
| Social well-being | 15.23 ± 4.47 | 15.78 ± 2.93 | 0.912 | .361 |
| Emotional well-being | 12.33 ± 5.17 | 13.33 ± 3.12 | 1.461 | .157 |
| Functional well-being | 16.86 ± 3.14 | 16.45 ± 3.78 | 1.546 | .121 |
| Specific colorectal cancer subscale | 19.21 ± 5.37 | 20.43 ± 6.32 | 1.317 | .196 |
| Total points | 75.71 ± 9.53 | 76.82 ± 12.56 | 0.632 | .534 |
| Post | ||||
| Physiological well-being | 16.41 ± 4.39 | 17.78 ± 6.12 | 1.614 | .113 |
| Social well-being | 16.74 ± 5.48 | 18.17 ± 4.78 | 1.742 | .081 |
| Emotional well-being | 14.19 ± 5.14 | 16.18 ± 4.17 | 2.665 | .009 |
| Functional well-being | 17.85 ± 4.12 | 19.47 ± 5.05 | 2.210 | .029 |
| Specific colorectal cancer subscale | 22.96 ± 5.14 | 23.57 ± 4.28 | 0.817 | .421 |
| Total points | 86.08 ± 8.56 | 96.13 ± 10.28 | 6.660 | <.001 |
SD = standard deviation.
4. Discussion
This study evaluated the impact of focused psychological care combined with enteral nutrition on CRC patients undergoing chemotherapy. The results demonstrated that the observation group experienced significantly greater improvements in anxiety, depression, psychological resilience, nutritional status, complication rates, and quality of life compared to the control group. These findings suggest that focused psychological care, when combined with enteral nutrition, can effectively enhance therapeutic outcomes and improve the overall quality of life for CRC patients undergoing chemotherapy.
The substantial reduction in both the SAS and SDS scores in the observation group, with improvements notably greater than those observed in the control group, provides clinically significant evidence of the impact of psychological interventions. A meaningful improvement in anxiety and depression is often defined as a change of 5 to 10 points on the SAS or SDS, which typically corresponds to a noticeable reduction in symptom severity and a clinically significant enhancement in mental well-being. These reductions in anxiety and depression are crucial in the context of cancer care, as untreated psychological distress can impair treatment adherence, exacerbate physical symptoms, and worsen overall prognosis. Focused psychological care, which includes CBT, emotional support, and relaxation techniques, has been shown to alleviate chemotherapy-related negative emotions and improve patients’ coping strategies. This aligns with previous studies indicating that psychological interventions significantly improve the mental well-being of cancer patients, particularly during chemotherapy.[15,16]
Moreover, the observation group demonstrated significant improvements in psychological resilience, including areas such as optimism and overall resilience, with improvements markedly superior to those of the control group. A clinically meaningful improvement in psychological resilience is often associated with an increase in resilience scores of 5 to 10 points on validated scales like the CD-RISC. The enhancement of psychological resilience contributes to better treatment outcomes and quality of life by strengthening coping mechanisms and increasing patients’ confidence in managing the challenges posed by chemotherapy. Psychological interventions can significantly boost patients’ ability to adapt to stressors, thereby facilitating better emotional and functional recovery.[17] The findings of this study suggest that psychological care not only supports emotional well-being but also enhances the patient’s ability to navigate the physical and emotional challenges of cancer treatment.
In terms of nutritional status, the observation group showed significant improvements in BMI, SGA score, PA, serum total protein (TP), and albumin (ALB), while no significant changes were observed in the control group. This demonstrates the critical role of enteral nutrition in improving the nutritional status of CRC patients undergoing chemotherapy. A meaningful improvement in nutritional status, particularly in cancer patients, is typically defined by increases in BMI, albumin levels, and SGA scores that are associated with better survival rates and fewer treatment interruptions. Enteral nutrition not only helps to restore weight but also plays a vital role in reducing chemotherapy-induced malnutrition, improving gastrointestinal function, and enhancing immune response.[18,19] By improving nutritional intake, enteral nutrition supports the body’s ability to withstand the physical stresses of chemotherapy and enhances treatment tolerance, which can contribute to better overall survival outcomes.[20] The results of this study are consistent with literature highlighting the importance of enteral nutrition in supporting the nutritional needs of cancer patients undergoing chemotherapy.
The incidence of common chemotherapy side effects, such as nausea and vomiting, loss of appetite, bloating, diarrhea, and phlebitis, was significantly lower in the observation group compared to the control group. This suggests that the combination of focused psychological care and enteral nutrition may have a synergistic effect on mitigating chemotherapy-related side effects. Chemotherapy-induced side effects, particularly gastrointestinal symptoms, are often a major barrier to treatment adherence and can significantly affect patients’ quality of life. Psychological interventions, particularly those targeting anxiety and stress, have been shown to reduce the perception of chemotherapy-related side effects, improving patients’ ability to manage these symptoms.[21] Furthermore, enteral nutrition helps alleviate symptoms like nausea and vomiting by improving gastrointestinal function and providing essential nutrients that support overall health.[22]
In this study, the improvement in emotional well-being, functional well-being, and overall quality of life was significantly greater in the observation group compared to the control group. Quality of life is a critical outcome measure in cancer treatment, as it reflects not only physical health but also emotional, social, and functional well-being.[23] The combination of focused psychological care and enteral nutrition plays a vital role in enhancing patients’ physical and psychological health. Psychological care fosters a positive mindset, builds resilience, and promotes optimism, which in turn supports overall well-being. Additionally, enteral nutrition improves the physical health of patients by addressing nutritional deficiencies, boosting immune function, and reducing the severity of side effects, thereby improving treatment tolerance and quality of life.[24] Together, these interventions contribute to an overall improvement in patients’ quality of life, as they address both the emotional and physical challenges of cancer treatment.
While the findings of this study are promising, the mechanisms underlying the combined effect of psychological care and nutritional support require further exploration. From a biopsychosocial perspective, psychological care and enteral nutrition may interact in ways that enhance the body’s ability to manage stress and improve physiological functioning. The biopsychosocial model emphasizes the interconnectedness of biological, psychological, and social factors in health outcomes. In this study, psychological care may have improved patients’ emotional and psychological resilience, leading to a reduction in stress-related physiological responses, while enteral nutrition supported physical recovery by improving immune function and nutritional status. Together, these factors could create a synergistic effect that enhances overall recovery and quality of life. Future research should aim to explore these mechanisms in more detail, perhaps by integrating concepts from integrative oncology, which recognizes the importance of combining conventional medical treatment with supportive interventions like psychological care and nutritional support to optimize cancer care.
This study has several limitations. First, it was conducted at a single center, which may limit the generalizability of the findings to broader, more diverse populations. Additionally, the non-randomized design introduces potential selection bias, as patients were not randomly assigned to the intervention or control group, and the results may be influenced by confounding factors not accounted for. A future prospective, randomized controlled trial would be valuable to eliminate selection bias and provide more robust evidence. The study also lacked blinding of participants and assessors, which could introduce performance or detection biases, especially with subjective measures like anxiety and depression. Furthermore, the follow-up period was relatively short, focusing only on the treatment phase, and long-term outcomes were not assessed. Extending the follow-up period would help evaluate the sustainability of the interventions’ benefits. While logistic regression was used to adjust for some confounding variables, there may be other unmeasured factors, such as socio-economic status or medication adherence, that could influence the outcomes. The study’s findings may also not be generalizable to patients undergoing subsequent chemotherapy cycles or those with significant comorbidities, as they were excluded from the study. Finally, although validated psychological and nutritional assessment tools were used, they may not fully capture the complexity of psychological resilience or the nutritional status of cancer patients, suggesting that future studies could incorporate a broader range of assessments for a more comprehensive evaluation. Despite these limitations, the study provides valuable insights into the benefits of combined psychological care and enteral nutrition for CRC patients undergoing chemotherapy, but further research is needed to strengthen these findings and increase their generalizability.
The findings of this study suggest that focused psychological care combined with enteral nutrition has the potential to improve anxiety, depression, psychological resilience, nutritional status, complication rates, and quality of life in patients undergoing chemotherapy for colorectal cancer (CRC). However, these results should be interpreted with caution, as the study’s methodology, including its non-randomized design and single-center setting, limits the ability to generalize the findings. Further replication in larger, controlled studies is needed to confirm the effectiveness and broader applicability of this integrated care model. While the study indicates potential clinical value, successful implementation in clinical practice would require skilled psychological intervention and nutritional management by trained nursing staff to ensure the effectiveness and sustainability of the intervention.
Author contributions
Conceptualization: Li Wu, Xiaoyan Meng.
Data curation: Li Wu, Xiaoyan Meng.
Formal analysis: Li Wu, Xiaoyan Meng.
Investigation: Li Wu, Xiaoyan Meng.
Methodology: Li Wu, Xiaoyan Meng.
Supervision: Li Wu, Xiaoyan Meng.
Validation: Li Wu, Xiaoyan Meng.
Visualization: Li Wu, Xiaoyan Meng.
Writing – original draft: Li Wu, Xiaoyan Meng.
Writing – review & editing: Li Wu, Xiaoyan Meng.
Abbreviations:
- ALB
- serum albumin
- BMI
- body mass index
- CD-RISC
- Connor–Davidson psychological resilience scale
- CRC
- colorectal cancer
- EORTC QLQ-C30
- European Organisation for Research and Treatment of Cancer Quality of Life Scale
- PA
- prealbumin
- SAS
- self-assessment anxiety scale
- SDS
- self-assessment depression scale
- SGA
- subjective global assessment
- TP
- total protein
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Wu L, Meng X. Analysis of the impact of focused psychological nursing combined with enteral nutrition during chemotherapy for colorectal cancer: A retrospective cohort study. Medicine 2025;104:35(e43318).
References
- [1].Dekker E, Tanis PJ, Vleugels JLA, Kasi PM, Wallace MB. Colorectal cancer. Lancet. 2019;394:1467–80. [DOI] [PubMed] [Google Scholar]
- [2].DeCosse JJ, Tsioulias GJ, Jacobson JS. Colorectal cancer: detection, treatment, and rehabilitation. CA Cancer J Clin. 1994;44:27–42. [DOI] [PubMed] [Google Scholar]
- [3].Brody H. Colorectal cancer. Nature. 2015;521:S1. [DOI] [PubMed] [Google Scholar]
- [4].Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018;68:394–424. [DOI] [PubMed] [Google Scholar]
- [5].Arnold M, Sierra MS, Laversanne M, Soerjomataram I, Jemal A, Bray F. Global patterns and trends in colorectal cancer incidence and mortality. Gut. 2017;66:683–91. [DOI] [PubMed] [Google Scholar]
- [6].Schmoll HJ. Colorectal carcinoma: current problems and future perspectives. Ann Oncol. 1994;5(Suppl 3):115–21. [DOI] [PubMed] [Google Scholar]
- [7].Bekradda M, Cvitkovic E. New possibilities in chemotherapy for colorectal cancer. Ann Oncol. 1999;10(Suppl 6):105–11. [PubMed] [Google Scholar]
- [8].Barbour SY. Management of patients with chemotherapy-induced nausea and vomiting. J Adv Pract Oncol. 2017;8:303–8. [PMC free article] [PubMed] [Google Scholar]
- [9].Alwhaibi M, AlRuthia Y, Sales I. The impact of depression and anxiety on adult cancer patients’ health-related quality of life. J Clin Med. 2023;12:2196. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [10].Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic colorectal cancer patients: results of an AGEO prospective multicenter study. Oncology (Huntingt). 2011;81:395–402. [DOI] [PubMed] [Google Scholar]
- [11].Duckworth AL, Steen TA, Seligman ME. Positive psychology in clinical practice. Annu Rev Clin Psychol. 2005;1:629–51. [DOI] [PubMed] [Google Scholar]
- [12].Krebber AM, Buffart LM, Kleijn G, et al. Prevalence of depression in cancer patients: a meta-analysis of diagnostic interviews and self-report instruments. Psychooncology. 2014;23:121–30. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [13].Nie J, Su X, Wei L, Li H. Early enteral nutrition support for colon carcinoma patients can improve immune function and promote physical recovery. Am J Transl Res. 2021;13:14102–8. [PMC free article] [PubMed] [Google Scholar]
- [14].Akbulut G. New perspective for nutritional support of cancer patients: enteral/parenteral nutrition. Exp Ther Med. 2011;2:675–84. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Distress Management (Version 2.2020). National Comprehensive Cancer Network; 2020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [16].Singer P, Blaser AR, Berger MM, Al-Hasani H, Calder PC, Correia MITD. ESPEN guideline on clinical nutrition in oncology. Clin Nutr. 2019;38:31–41. [Google Scholar]
- [17].Ośmiałowska E, Misiąg W, Chabowski M, Jankowska-Polańska B. Coping strategies, pain, and quality of life in patients with breast cancer. J Clin Med. 2021;10:4469. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [18].Baiu I, Spain DA. Enteral nutrition. JAMA. 2019;321:2040. [DOI] [PubMed] [Google Scholar]
- [19].Vitaloni M, Caccialanza R, Ravasco P, et al. The impact of nutrition on the lives of patients with digestive cancers: a position paper. Support Care Cancer. 2022;30:7991–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [20].Evans WK, Nixon DW, Daly JM, et al. A randomized study of oral nutritional support versus ad lib nutritional intake during chemotherapy for advanced colorectal and non-small-cell lung cancer. J Clin Oncol. 1987;5:113–24. [DOI] [PubMed] [Google Scholar]
- [21].Numico G, Longo V, Courthod G, Silvestris N. Cancer survivorship: long-term side-effects of anticancer treatments of gastrointestinal cancer. Curr Opin Oncol. 2015;27:351–7. [DOI] [PubMed] [Google Scholar]
- [22].Allan SG. Mechanisms and management of chemotherapy-induced nausea and vomiting. Blood Rev. 1987;1:50–7. [DOI] [PubMed] [Google Scholar]
- [23].Park KU. Assessment of change of quality of life in terminally ill patients under cancer pain management using the EORTC core quality of life questionnaire (QLQ-C30) in a Korean sample. Oncology (Huntingt). 2008;74:7–12. [DOI] [PubMed] [Google Scholar]
- [24].Martin L, Birdsell L, Macdonald N, et al. Cancer cachexia in the age of obesity: skeletal muscle depletion is a powerful prognostic factor, independent of body mass index. J Clin Oncol. 2013;31:1539–47. [DOI] [PubMed] [Google Scholar]