Depression among women with cervical cancer: a systematic review and meta-analysis of available evidence

Abstract

Background

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. Cervical cancer remains a significant global health challenge, particularly affecting women in low- and middle-income countries. Beyond its physical implications, cervical cancer is associated with a high prevalence of depression, which adversely impacts patients’ quality of life and treatment outcomes. Understanding the global prevalence and associated factors of depression among women with cervical cancer is essential for developing targeted mental health interventions and improving comprehensive cancer care. The definition and “cutting point” (threshold) of depression is a critical piece of psychiatric literature. It challenges the medical assumption that Major Depressive Disorder (MDD) is a discrete, biological category that one either “has” or “does not have.”

Methods

This systematic review and meta-analysis adhered to PRISMA guidelines to assess the pooled prevalence of depression among women with cervical cancer worldwide. A comprehensive search was conducted across PubMed, Google Scholar, Science Direct, and other databases up to February 05 ,2026. Studies included were original, English-language research employing cross-sectional, case-control, cohort, or descriptive designs that reported prevalence data. Data from 20 eligible articles involving 23,825 participants were extracted and analysed using STATA version 17. A random-effects model estimated the pooled prevalence, with heterogeneity assessed via I² and subgroup analyses conducted based on study year, continent, and study design.

Results

The pooled prevalence of depression among women with cervical cancer was estimated at 38.02% (95% CI: 29.00%, 47.05%), with significant heterogeneity (I² = 99.6%). Subgroup analysis revealed higher prevalence rates in studies conducted in Africa (52.51%) and after 2020 (49.15%), whereas studies in Europe reported lower rates (12.26%). The prevalence was higher in cross-sectional studies (48.80%) compared to other designs. Publication bias was detected, and the trim-and-fill method adjusted the pooled prevalence to approximately 24.27%. Sensitivity analysis confirmed the robustness of these findings.

Conclusion and recommendations

Depression is highly prevalent among women with cervical cancer globally, underscoring the necessity for routine mental health screening and psychosocial support integration into cancer care. The significant heterogeneity and regional disparities highlight the importance of context-specific interventions. Healthcare providers should incorporate systematic depression screening and mental health services into cervical cancer management protocols.

Clinical trial number

Not applicable.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12888-026-08211-w.

Introduction

Cervical cancer, a neoplasm of malignancy arising from the transformation zone of the cervix, represents a significant global health issue, particularly for women. According to GLOBOCAN 2022 statistics, cervical cancer ranks as the eighth most common cancer worldwide, accounting for approximately 662,000 new cases and 349,000 deaths annually, which corresponds to 3.3% and 3.6% of total cancer incidence and mortality, respectively [1].

Cervical cancer remains a preeminent challenge in global oncology, ranking as the most prevalent gynaecologic malignancy among women. Cervical cancer is the fourth most common cancer type in women worldwide in terms of both incidence and mortality, with an estimated 570 000 new cases and 311 000 deaths in 2018. Thirteen sexually transmitted mucosal HPV subtypes have been classified as carcinogenic to humans. Together, they are responsible for all cervical cancer cases globally [2].

Cancer incidence and mortality have been increasing in China, making cancer the leading cause of death since 2010 and a major public health problem in the country. Much of the rising burden is attributable to population growth and ageing and to sociodemographic changes [3].

Cancer is a serious and potentially life-threatening illness that negatively affects both the physical and psychological well-being of patients. The diagnosis and treatment of cancer are considered major life stressors and can cause or worsen psychological distress [1].

Depression is a mood disorder that causes a persistent feeling of sadness and loss of interest. The American Psychiatric Association’s Diagnostic Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifies the depressive disorders into Disruptive mood dysregulation disorder; Major depressive disorder; Persistent depressive disorder (dysthymia); Premenstrual dysphoric disorder; and Depressive disorder due to another medical condition. The common features of all the depressive disorders are sadness, emptiness, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function [4].

The PHQ-9 scoring range is from 0 to 27, with a cut off score of 10 or higher widely recognized as the “clinical gold standard” for detecting Major Depressive Disorder (MDD) [5]. The HADS is distinctive because it omits physical symptoms such as insomnia or fatigue, reducing the risk of “false positives” in patients with physical illnesses [6]. The standard cut-off score ( > = 7–8) typically suggests the presence of “possible” or mild depressive symptoms. A score of > = 10 is commonly used to indicate “probable” or moderate-to-severe depression. BDI > = Standard Cut-off ( > = 14): Typically indicates the onset of “mild” depression. Pre-pandemic threshold ( > = 14.5): Historically referenced in earlier studies as the optimal balance point for sensitivity and specificity prior to the global shift in mental health patterns [7].

Depression among women diagnosed with cervical cancer is a significant mental health concern, reflecting the profound psychological impact of the disease. Cervical cancer, one of the most common cancers affecting women worldwide, affects not only physical health but also mental well-being. Studies indicate that depression rates among patients range from 33% to 76%, which is markedly higher than those in other gynaecologic cancer populations [8]. Women diagnosed with cervical cancer often experience various psychological and social challenges, particularly concerning their mental health. Studies indicate that the prevalence of depression among cervical cancer patients in China ranges from 31.5% to 76%, highlighting a concerning trend [9]. A different study showed that almost 68% of people with cervical cancer also had depression. This shows that depression is common in people with cervical cancer [10].

The mental health of cervical cancer patients can be significantly affected by their social circumstances, such as their socioeconomic status and support systems. Studies demonstrate that patients with lower incomes and educational attainment exhibit a higher prevalence of depression [11, 12].

Studies show that from 33% to 52% of people with cervical cancer are also depressed. This is much higher than the about 21% of people with other types of Gynaecological cancer who are depressed [13]. A study involving 30 women treated for cervical cancer reported that 56.6% of the participants exhibited pathological levels of anxiety and depression. In addition, an investigation of 40 Tunisian women in remission revealed that 60% of them experienced anxiety, while 57.5% dealt with depression. These rates were particularly high among those facing advanced disease stages or undergoing extensive treatments, such as hysterectomy or external radiotherapy [14].

Studies show that women experiencing significant disparities in income are at a greater risk for depressive symptoms, which are symptoms of a mental health condition that can include feelings of sadness, hopelessness, and an inability to enjoy life. Physical health issues, including pain and poor body image, can also contribute to depression in cervical cancer patients. Moderate to severe pain is correlated with increased rates of depression, as is sexual inactivity, which can affect self-esteem and body image [14, 15].

Research shows that having more social connections can improve mental health and overall health. This highlights the importance of combining mental health and social support for people with cancer [16]. Programs that foster resilience through psychological counselling and community support have shown promise in improving both mental health and quality of life for women facing cervical cancer treatment [17, 18].

The reason for this review of research studies is that cervical cancer is still a major global health problem, especially in low and middle income countries, and is linked to a high rate of depression among the affected women. Depression adversely impacts patients’ quality of life and treatment outcomes, yet the true extent and regional variations of this mental health issue are not well-defined on a global scale. Existing studies report varying prevalence rates, which are often influenced by different methodologies, diagnostic criteria and sociocultural factors. What is needed is a synthesis of the available evidence to determine the pooled prevalence of depression among women with cervical cancer around the world. This comprehensive understanding is essential for informing healthcare policies, integrating mental health screening into cancer care and designing targeted interventions to improve the holistic management of cervical cancer patients in different settings.

Methods

This systematic review was carried out in accordance with the strict standards of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) to ensure a full and comprehensive study. A consistent framework for carrying out systematic reviews is offered by these guidelines.

Research/review question

The review questions for this study are:

What is the Global pooled prevalence of depression among women with cervical cancer?

Coco Pop

• Condition = Assessing the depression.

• Context = Global context.

• Population = Women.

Eligibility criteria

The inclusion criteria for this review were thoughtfully established, focusing on three main aspects. First, the study needed to be original, providing new and unique findings rather than simply replicating prior research. Second, the research had to be conducted and reported in English language. Lastly, the study’s outcomes were restricted to the prevalence of depression among women with cervical cancer who visited the health institutions, specially hospitals. Articles published in languages other than English, reviews, case series, editorial, commentary, qualitative studies, studies with missing outcomes of interest, and articles that failed to fulfil the aforementioned eligibility criteria were excluded from this review.

Data source and searching strategy

The primary objective of this comprehensive study was the analysis of depression. A systematic review and meta-analysis were performed by examining articles from national and international databases to ensure a thorough and accurate assessment. This involved PubMed, Direct science, Google Scholar, and up until February 05, 2026, by using Key words “epidemiology“[Subheading] OR “prevalence“[MeSH Terms] OR prevalence [Text Word] AND “depressive disorder“[MeSH Terms] OR “depression“[MeSH Terms] OR depression [Text Word] AND “uterine cervical neoplasms“[MeSH Terms] OR cervical cancer [Text Word] AND “women“[MeSH Terms] OR women [Text Word]. We also utilized Scopus and other major databases, particularly during the literature search phase for writing the introduction session. Direct Google searches and library searches were also conducted to identify potential grey literature that may have been missed in the initial database searches using specific key words and mesh terms. Reference lists of identified trials and reviews were cross-checked to find additional studies. We used a predefined search strategy and specific terms across all databases to ensure the search was both consistent and exhaustive (supplement document).

Study area

The scope of the research was wide, with studies from a number of different countries being part of the research. This enabled a comprehensive and diverse analysis of the issue. Each country provided a more nuanced understanding of the issue, bringing its own unique perspective and findings, which contributed to a more comprehensive understanding of the issue. The study was able to take a wide view by including studies from all around the world. This avoided any potential bias or limitations that might have arisen from focusing on one region. It also made sure that the examination of the issue was more comprehensive by considering a wide range of cultural, social, and economic factors in the overall analysis.

Study design

In this review, a cross-sectional, case control, retrospective and prospective cohort and descriptive study design were taken. Studies with original data on prevalence of depression and associated factors among cervical cancer patients/women were specifically selected.

Language

Literatures published in the English language was included.

Population

Studies conducted among cervical cancer patients/women were considered.

Publication condition: Both published and unpublished articles were considered. All published studies and grey literature February 05 ,2026, were considered for the review. Duplicate studies: The most comprehensive and/or recent study with the largest sample size was chosen during the abstraction.

Data abstraction

To ensure thorough and accurate selection of relevant articles, a team of seven reviewers (MMT, WM, TA, GT, WT, AK and ED) independently screened titles and abstracts of retrieved material against predetermined inclusion criteria. Subsequently, three authors (GB, MA and HA) conducted a comprehensive review of the full-text articles to assess their relevance based on objectives, methods, population, and key findings. Any disagreements were resolved through discussions and consultations with the remaining four investigators (KS, MG, EG and ML). Following this rigorous selection process, a significant number of publications were identified as meeting the necessary criteria for inclusion in the study. Microsoft Excel 2016 format was used to extract the data from selected studies under the following headings: author name, year of publication, year of study, study setting, study design, sample size, and prevalence of depression (Table 1).

Table 1.

Characteristics of the studies included in the systematic review and meta-analysis

No	Author	study year	study yr cat	country	Continent	study design	treatment received	diagnoses methods	diagnostic criteria	sample size	sample cat	As depression	p	se of p
1	Kebebew et al., 2021	2019	Before 2019	Ethiopia	Africa	Cross-sectional	Radiotherapy	patient-reported,	others	385	Less than 150	181	47.0	2.543684695
2	Dr. Ravi et al., 2016	2014	Before 2019	Zambia	Africa	Cross-sectional	cryotherapy	patient-reported,	becks depression inventory	102	Less than 150	82	80.4	3.931168565
3	Samuel M et al., 2025	2022	Before 2019	Uganda	Africa	Cross-sectional	cryotherapy and thermocoagulation	by a healthcare professional	PHQ-9	112	Greater than 150	20	17.9	3.618944122
4	Rym Z et al., 2024	2022	After 2019	Tunisia	Africa	Cross-sectional	Radiotherapy and chemotherapy	by a healthcare professional	HADS and DTS	40	Greater than 150	23	57.5	7.8162491
5	Khalfi S et al., 2025	2024	After 2019	Morocco	Africa	Cross-sectional	Radiotherapy	by a healthcare professional	HADS	100	Greater than 150	25	25.0	4.330127019
6	Husna S et al., 2021	2021	After 2019	Kenya	Africa	Cross-sectional	cryotherapy and surgery	by a healthcare professional	HADS	103	Greater than 150	90	87.4	3.272179307
7	Devana N et al., 2022	2021	After 2019	Indonesia	Asia	descriptive-analytic	cryotherapy and thermocoagulation	patient-reported,	becks depression inventory	45	Less than 150	15	33.3	7.027283689
8	Mamta D et al., 2023	2022	After 2019	Nepal	Asia	Cross-sectional	Radiotherapy	by a healthcare professional	becks depression inventory	140	Less than 150	95	67.9	3.947080701
9	Zhaqirra S et al., 2025	2024	After 2019	Indonesia	Asia	descriptive-analytic	not specified	patient-reported,	becks depression inventory	54	Greater than 150	19	35.2	6.498605637
10	Shyu et al. 2019	2005	Before 2019	Taiwan	Asia	cohort	not specified	by a healthcare professional	others	19,316	Less than 150	813	4.2	0.144474284
11	Nuntaporn K et al., 2023	2021	After 2019	Thailand	Asia	Cross-sectional	not specified	by a healthcare professional	DSM	200	Greater than 150	27	13.5	2.416350554
12	Sasiwimon P et al., 2018	2018	Before 2019	Thailand	Asia	case-control	not specified	by a healthcare professional	HADS	200	Greater than 150	1	0.5	0.498748434
13	Jorge C et al., 2023	2019	Before 2019	Spain	Europ	cohort	Radiotherapy	by a healthcare professional	HADS	106	Greater than 150	13	12.3	3.186062952
14	Nimisha M et al., 2015	2009	Before 2019	India	Asia	Cross-sectional	cryotherapy	by a healthcare professional	HADS	30	Less than 150	7	23.3	7.72202238
15	Soo Hyun K et al., 2010	2004	Before 2019	Korea	Asia	case-control	Surgery, radiotherapy and chemotherapy	by a healthcare professional	HADS	828	Greater than 150	286	34.5	1.652483587
16	S Kim et al., 2009	2009	Before 2019	Korea	Asia	Cross-sectional	not specified	by a healthcare professional	HADS	832	Greater than 150	330	39.7	1.695992155
17	Xuan W et al., 2019	2018	Before 2019	China	Asia	cohort	surgery and chemotherapy	by a healthcare professional	HADS	48	Greater than 150	10	20.8	5.861785769
18	Yi-Long Y et al., 2014	2013	Before 2019	China	Asia	Cross-sectional	Surgery, radiotherapy and chemotherapy	by a healthcare professional	HADS	224	Greater than 150	117	52.2	3.337434816
19	Deying H et al., 2023	2022	After 2019	China	Asia	Cross-sectional	radiotherapy and chemotherapy	by a healthcare professional	PHQ-9	802	Greater than 150	583	72.7	1.573239284
20	Hongmei Z et al., 2019	2013	Before 2019	China	Asia	cohort	surgical resection	by a healthcare professional	HADS	158	Greater than 150	57	36.1	3.82043209

Quality assessment

The Newcastle Ottawa Scale (NOS), which assesses study quality and potential sources of bias, was used to assess the risk of bias [19]. The representativeness of the sample, methodological quality, determination of risk, study comparability, evaluation of results, and statistical tests were used to evaluate the studies’ quality. High-quality studies were those that received a score of seven or more out of ten. The quality of the studies for inclusion in the analysis was assessed independently by each author (Supplementary Table 2).

Outcome measurements

Prevalence of depression among women with cervical cancer across the world, was calculated in this systematic review and meta- analysis using prevalence and their 95% confidence inter- vales (CI).

Data processing and statistical analysis

The data were extracted and cleaned using Microsoft Excel spreadsheets, then exported to STATA version 17 for analysis. STATA version 17 was utilized to calculate the pooled effect size with 95% confidence intervals (CIs) for the prevalence of depression among women with cervical cancer. A meta-analysis was conducted using a weighted inverse variance random-effects model to pool the prevalence of depression among women across the world with a 95% confidence interval.

The heterogeneity of the studies was assessed using the Cochrane I² with its corresponding p-value. Therefore, this study identifies significant heterogeneity, with I² values of 99.73% for practice, and a p-value of 0.00. To investigate the sources of heterogeneity, subgroup analyses were conducted based on sample size, publication year of the studies, study setting and study design. A sensitivity analysis was conducted to assess how individual studies influenced the overall findings and to evaluate the robustness of the overall estimate. Each study was systematically removed one at a time, and the overall effect size was recalculated accordingly. We were able to determine the contribution and impact of each study on the total estimate by comparing the estimates obtained with and without each study. This process provided valuable insight into the stability of the results across different study configurations and helped identify any studies that might substantially affect the overall conclusions. Additionally, publication bias was evaluated using Egger’s test and visual inspection of a funnel plot symmetry.

A total of 100 articles were gathered from various sources to assess the prevalence of depression among women with cervical across the world. Of these, 35 articles were excluded due to duplication. Additionally, 20 articles were removed after assessing the titles, and 10 were discarded following the review of abstracts. From remaining 35 articles, 10 were eliminated due to having irrelevant content or failing to meet the inclusion criteria and 5 articles were excluded because the full content could not be accessed. Finally, the analysis included 20 articles which were met the inclusion criteria (Fig. 1).

Fig. 1.

Flow chart of selection for systematic review and meta-analysis of depression among women with cervical cancer across the world, 2026

Result

Characteristics of the studies and the search results

A total of 20 articles with 23,825 participants were included in this systematic review and meta-analysis. Studies with cross-sectional, descriptive study, case control and cohort study designs were included and the sample size ranged from 30 to 19,316. Among these studies, one study was conducted in Ethiopia [20], one in Zambia [21], one in Uganda [22], one in Tunisia [23], one in Morocco [14], one in Kenya [24], one in Nepal [10], one in Spain [25], one in India [26], one in Taiwan [27], two in Indonesia [28, 29], two in Thailand [30, 31], two in Korea [32, 33] and four studies in China [1, 15, 34, 35]. From all the studies twelve studies were used cross sectional study design, two studies used case control study design, two descriptive studies and the remaining four studies used cohort study design.

Prevalence of depression

Twenty-three thousand eight hundred twenty-five (23,825) participants were analysed to determine the pooled prevalence of depression among women with cervical cancer. By using the random-effect model, the overall pooled prevalence of depression among women with cervical cancer across the world was estimated to be 38.02% (95% CI: 29.00%, 47.05%); I² = 99.6%, p < 0.001) (Fig. 2).

Fig. 2.

Forest plot showing the pooled prevalence of depression among women with cervical cancer in world wide

Publication bias

The presence of publication bias was assessed using Egger’s test and a funnel plot. The funnel plot for the prevalence of depression among women with cervical cancer was asymmetric, indicating the presence of publication bias (Fig. 3). Additionally, Egger’s test showed a significant p-value of 0.001, confirming the presence of significant publication bias in the articles.

Fig. 3.

The funnel plot shows the presence of publication bias

Trim-and-fill analysis

The trim-and-fill method was applied to manage publication bias for the prevalence of depression among women with cervical cancer. Six studies were identified as “missing.” They were on the left side of the funnel plot. This side had a lower prevalence. Observed Pooled Prevalence: 38.02% (95% CI: 29.00% – 47.05%). Adjusted Pooled Prevalence: 24.27% (95% CI: 16.25% – 32.30%). The analysis suggests that the original pooled prevalence of 38% is likely an overestimate. This is due to the “small-study effect,” where smaller studies reporting high prevalence are more likely to be published than those reporting low prevalence. After imputing the 6 missing studies to restore symmetry to the funnel plot, the “true” adjusted prevalence is estimated to be approximately 24%. In the graph, the original studies are shown as solid blue circles. The imputed studies are shown as open circles with diagonal hatching (Fig. 4).

Fig. 4.

Trim and fill funnel plot for prevalence of depression among women with cervical cancer

Heterogeneity

The heterogeneity of the studies was assessed using I² and its corresponding p-value. This study found significant heterogeneity, with I² values of 99.6% and a p-value of 0.00 for prevalence of depression. This suggests the need for subgroup analysis. To explore the source of this heterogeneity, we conducted subgroup analyses based on several factors: the study year, continent and study design. However, the subgroup analysis did not identify the source of the heterogeneity, as the I² value remained high, indicating significant variability.

Sub group analysis by study year

The pooled prevalence of depression, based on the year of the study, indicated that studies conducted after COVID 19 pandemic (2019) showed higher proportions (49.19%(95% CI:30.86, 67.52)) compared to those conducted before COVID 19 pandemic (2019) (prevalence = 30.72% (95% CI: 17.87, 43.57)) (Fig. 5).

Fig. 5.

The pooled prevalence of depression among women with cervical cancer by the study year

Sub group analysis by continents

The pooled prevalence of depression, based on the continents sub group analysis, indicated that studies conducted in Africa showed higher proportions (52.51%(95% CI:27.17, 71.13)) compared to those conducted in Asia (prevalence = 33.40% (95% CI: 23.47, 43.33)) and Europe (prevalence = 12.26% (95% CI: 6.02, 18.51)) (Fig. 6).

Fig. 6.

The pooled prevalence of depression among women with cervical cancer, based on the continents sub group analysis

Sub group analysis by study design

The pooled prevalence of depression, based on the study design sub group analysis, indicated that studies conducted with crossectional study design was showed higher proportions (48.80%(95% CI:34.45, 63.14)) compared to those conducted with other designs (Fig. 7).

Fig. 7.

The pooled prevalence of depression among women with cervical cancer, based study design

Subgroup analysis by treatment received

The pooled prevalence of depression, based on the treatment received sub group analysis, indicated that studies conducted on the patient who received both chemotherapy and radiotherapy treatment was showed higher proportions (57.50%(95% CI:42.18, 72.82)) compared to those conducted with patients who received other treatment (Fig. 8).

Fig. 8.

The pooled prevalence of depression among women with cervical cancer, based on treatment received

Subgroup analysis by diagnostic criteria

The pooled prevalence of depression, based on the diagnostic criteria sub group analysis, indicated that studies conducted by using becks depression inventory was showed higher proportions (54.74%(95% CI:31.61, 77.87)) compared to those conducted by using other diagnostic criteria (Fig. 9).

Fig. 9.

The pooled prevalence of depression among women with cervical cancer, based on diagnostic criteria

Subgroup analysis by the method of diagnoses were made

The pooled prevalence of depression, based on subgroup analysis by method of diagnosis, indicated that diagnoses made through patient reports showed a higher proportion (49.43% [95% CI: 27.93, 70.94]) compared to diagnoses made by health professionals (Fig. 10).

Fig. 10.

The pooled prevalence of depression among women with cervical cancer, based on diagnostic method

Meta regression

Study Design is the most significant moderator identified, explaining 32.2% of the between-study variance. Continent also explains a substantial portion (18.2%). Conversely, the year of publication and sample size have minimal explanatory power. Cross-sectional studies tend to report strongest predictor to higher prevalence of depression compared to case-control studies (approx. 31% higher), which may reflect the difference between point-prevalence and longitudinal or clinical selection bias. Although not statistically significant at the p < 0.05 level, there is a clear downward trend in reported prevalence in European and Asian studies compared to African cohorts. The year of publication does not influence prevalence (p = 0.41) (Table 2).

Table 2.

Meta-regression analysis of potential moderators influencing the prevalence of depression among women with cervical cancer

Moderator	Variable	Coefficient	SE	P-value	95% CI
Study year	Study year	+ 0.79	0.93	0.410	-1.17, 2.75
Sample size	Sample size	-0.0018	0.001	0.179	-0.005, 0.001
Continent	Asia	-19.09	11.94	0.128	-44.29, 6.11
	Europe	-40.23	25.90	0.139	-94.87, 14.42
Study design	Cross-sectional	+ 31.37	17.03	0.084	-4.73, 67.47
	Cohort	+ 0.71	19.35	0.971	-40.32, 41.74
	Descriptive	+ 16.80	22.83	0.472	-31.59, 65.19

Sensitivity analysis

A “Leave-One-Out” (LOO) analysis was performed to evaluate the stability of the pooled estimate. The pooled prevalence remained relatively stable, fluctuating between 35% and 40% regardless of which study was excluded. No single study shifted the pooled estimate outside the original 95% confidence interval. The Sensitivity Analysis confirms that the overall pooled estimate of ~ 38% is a reliable representation of the current evidence base and is not the result of a single “outlier” study (Fig. 11).

Fig. 11.

The Sensitivity analysis for prevalence of depression among women with cervical cancer

Discussion

Cervical cancer is still one of the most common female cancers in Asia and the leading cause of cancer-related deaths in low- and middle-income countries. Nowadays, national screening programs for cervical cancer are widely provided in Asian countries [36]. Globally, cervical cancer is the fourth commonest cancer among women with an estimated age-standardized incidence rate of 13.3 per 100,000 and age-standardized mortality rate as 7.3 per 100,000 women in 2020 [37]. A meta-analysis and systematic review were conducted in Ethiopia and China (factors only). However, our objective is to assess the pooled prevalence of depression among women with cervical cancer worldwide. This systematic review and meta-analysis, which is the first study across the world as per the knowledge of the researcher. To conduct this study a total of 20 eligible studies were included. As a result, the pooled prevalence of depression among women with cervical cancer across the world was estimated to be 38.02% (95% CI: 29.00%, 47.05%); I² = 99.6%, p < 0.001). This finding suggests that the pooled prevalence of depression among women with cervical cancer is higher than the 15.7% reported in a systematic review and meta-analysis conducted in Ethiopia (95% CI: 10.8% to 21.3%). This discrepancy may be attributed to differences in sample size, geographical location, and socio-demographic factors among the study populations [38]. Our study’s depression prevalence exceeds the 27% reported in the global meta-analysis of cancer patients overall, and aligns closely with the 38.02% (95% CI: 29.00–47.05%) pooled estimate specific to cervical cancer patients worldwide. This discrepancy likely stems from amplified biological mechanisms like inflammation and HPA-axis dysregulation from radiotherapy/tumor burden; psychological factors including fear of recurrence, infertility grief, and body image distress post-hysterectomy; and social contributors such as stigma linking cervical cancer to promiscuity, treatment-related financial toxicity, chronic pelvic pain, and sexual dysfunction (e.g., vaginal stenosis) [39].

The systematic review in our study estimates a global pooled prevalence of depression among women with cervical cancer at 38.02%. This finding aligns closely with the 36% (95% CI: 28–45%) prevalence reported in a meta-analysis of patients with Anemia, suggesting a high burden of psychological distress across these chronic conditions. The similarity in these figures underscores the significant mental health impact of managing chronic illnesses [40].

The pooled global prevalence of depression among women with cervical cancer is estimated at 38.02% (95% CI: 29.00–47.05%), based on 20 studies involving 23,825 participants up to February 2026. In contrast, a systematic review and meta-analysis on postpartum depression in India reports a prevalence of 19% (95% CI: 15–23%) from 59 publications covering 2020–2024, using a random effects model. This comparison indicates that the depression burden is approximately twice as high in women with cervical cancer compared to postpartum women, likely due to differences in population (cancer versus perinatal), geographic scope (Different region versus India-specific), and study period (up to 2026 versus 2020–2024) [41].

The highest prevalence was observed in a 2021 study conducted at Kenyatta National Hospital in Kenya (87.4%) [24], whereas the lowest point estimate was observed in a 2020 study conducted in Thailand (0.5%) [31]. A statistically significant heterogeneity was observed among the included studies (I² = 99.6%, p < 0.001).

Our pooled prevalence of 38.02% (95% CI: 29.00%, 47.05%) falls between individual Chinese studies reporting 65.6%. Although this is not a meta-analysis, the study on Chinese cervical patients reported a depression prevalence of 65.6%, suggesting our overall pooled prevalence is lower than this individual figure [1]. On the other hand, a single study in China found a depression prevalence of 36.1% among cervical cancer patients, which is slightly lower than our pooled estimate [35]. These discrepancies likely stem from sample size differences (e.g., smaller cohorts in high-prevalence studies), sociocultural variations (e.g., stigma around HPV-related cancers in China), and socioeconomic factors like urban-rural healthcare access.

Prevalence difference by study year

Although no significant difference in prevalence was found between studies conducted in different years, the pooled data revealed that studies conducted after 2019 reported a higher prevalence of depression (49.15%, 95% CI: 27.17% to 71.13%) compared to those conducted before 2019 (30.65%, 95% CI: 22.78% to 38.52%) (I² = 99.6%). The reason for this finding is post-2019 studies often captured patients with advanced disease stages. This is due to pandemic-related delays in diagnosis and radiotherapy. Radiotherapy is a known depression risk factor. Prolonged treatments and impaired physical functions created heightened financial burdens. These factors further elevated depression rates in later cohorts [9]. COVID-19 disrupted cancer care globally starting in 2019, delaying screenings, treatments, and surgeries for cervical cancer patients, which heightened psychological distress [42].

Prevalence depression by continent

The pooled prevalence of depression among women with cervical cancer, based on the continents sub group analysis, indicated that studies conducted in Africa showed higher proportions compared to those conducted in Asia and Europe (I² = 99.6%). The reason for this finding is Limited mental health resources and poverty in Africa exacerbate psychological distress from late-stage cervical cancer diagnoses, unlike better-supported systems in Europe and Asia. Africa’s higher cervical cancer burden, due to lower screening and HPV vaccination rates, compounds emotional strain on mothers [43]. Although both our study and the research on depression prevalence among Anemia patients employ meta-analyses with a random-effects model to address substantial heterogeneity; they reveal distinct regional disparities. The Anemia study indicates higher prevalence rates in Asia and Africa compared to Western regions, while the cervical cancer study reveals that Africa has a markedly higher prevalence (52.51%) than other areas, possibly attributable to resource constraints and diagnoses at more advanced stages [40].

Prevalence depression by study design

The pooled prevalence of depression, based on the study design sub group analysis, indicated that studies conducted with crossectional study design was showed higher proportions (48.80%(95% CI:34.64, 62.95)) compared to those conducted with other designs. The cross-sectional study design is the reason for this result. It captures depression at a single time point, emphasizing the current prevalence of the condition at that moment rather than its lifetime or period prevalence. This approach emphasizes the most common cases in the community, which are naturally higher since they include both new and ongoing cases. This is unlike longitudinal designs, which can track incidence or remission.

Subgroup analysis by treatment received

The subgroup analysis of treatment received revealed that the pooled prevalence of depression was higher among patients who underwent both chemotherapy and radiotherapy, with a rate of 57.50% (95% CI: 42.18 to 72.82). This prevalence was greater compared to patients who received other forms of treatment. The analysis by treatment type suggests that depression is more prevalent in patients receiving combined chemotherapy and radiotherapy, likely due to the increased physical and emotional stress associated with this intensified treatment, which may exacerbate psychological distress and elevate the risk of depression.

Subgroup analysis by diagnostic criteria

Subgroup analysis revealed that studies utilizing Beck’s Depression Inventory (BDI) reported a higher pooled prevalence of depression at 54.74% (95% CI: 31.61–77.87) among women with cervical cancer, compared to studies using other diagnostic tools. This higher rate may be attributed to BDI’s focus on cognitive and affective symptoms, which can detect subtler signs of depression than tools that emphasize somatic symptoms. These findings underscore the importance of establishing standardized screening protocols to ensure uniformity in mental health assessments across different studies.

Subgroup analysis by the method of diagnoses were made

Subgroup analysis by diagnostic method revealed key differences in reported depression prevalence among women with cervical cancer. Diagnoses based on patient self-reports showed a higher pooled prevalence of 49.43% (95% CI: 27.93–70.94) compared to those made by health professionals.

This disparity likely stems from self-report tools capturing subjective symptoms like sadness or hopelessness more sensitively, while professional diagnoses apply stricter clinical criteria, potentially underestimating cases.

Strengths and limitations of the study

The strengths of this study include a comprehensive and systematic literature search covering multiple databases and sources, inclusion of studies from diverse geographic regions to enhance the global understanding, subgroup analyses to explore sources of heterogeneity, and the use of Egger’s test to evaluate publication bias. However, limitations of the study include the restriction to studies published in English, which may limit the generalizability of the findings to non-English-speaking populations.

Additionally, most of the included studies originated from certain countries, such as China and Ethiopia, which may not fully represent the prevalence of depression among women with cervical cancer across all regions globally. The reliance on published studies introduces the potential for publication bias, possibly leading to an overestimation of the true prevalence of depression, particularly if studies with null or lower prevalence results were not published or included. Furthermore, the study did not separately assess publication bias for articles retrieved from different sources, such as Google Scholar, which might have varying levels of quality or reporting standards compared to other databases like PubMed, potentially affecting the robustness of the pooled estimates.

Conclusion and recommendation

Based on the systematic review and meta-analysis presented in cca.docx, it is evident that the prevalence of depression among women with cervical cancer is significantly high, estimated at approximately 38%, with substantial heterogeneity across different regions and study designs. This highlights the urgent need for integrating mental health assessment and psychosocial support into cervical cancer care globally, particularly in resource-limited settings such as Africa, where prevalence rates are higher. Healthcare systems should prioritize routine depression screening for cervical cancer patients, develop comprehensive psychological support programs, and enhance social support mechanisms. In addition, future studies should concentrate on pinpointing the particular elements leading to depression in various populations and assessing the efficacy of targeted interventions to enhance mental health outcomes and overall quality of life for women facing cervical cancer.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Abbreviations

BDI

Beck’s Depression Inventory

HPV

Human Papillomavirus

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

CI

Confidence Interval

NOS

Newcastle Ottawa Scale

STATA

Software for statistical analysis

I²

I-squared statistic (measure of heterogeneity)

Author contributions

To ensure thorough and accurate selection of relevant articles, a team of seven reviewers (MMT, WM, TA, GT, WT, AK and ED) independently screened titles and abstracts of retrieved material against predetermined inclusion criteria. Subsequently, three authors (GB, MA and HA) conducted a comprehensive review of the full-text articles to assess their relevance based on objectives, methods, population, and key findings. Any disagreements were resolved through discussions and consultations with the remaining four investigators (KS, MG, EG and ML). Following this rigorous selection process, a significant number of publications were identified as meeting the necessary criteria for inclusion in the study. All authors provided critical conceptual input, analyzed and interpreted the data, and critically revised the report, read and approved the final manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.