A Nursing Intervention Combining Case Management and CBT for Postoperative NSCLC Patients: Effects on Anxiety, Depression, and Quality of Life

Non-small cell lung cancer (NSCLC) is the most common type of lung cancer, named for the larger, cytoplasm-rich cells under the microscope, and accounts for about 85% of all lung cancer cases. It encompasses various histologic subtypes such as squamous carcinoma, adenocarcinoma, large cell carcinoma, squamous adenocarcinoma, and sarcomatoid carcinoma^1,2. The etiology of its development is complex. Smoking is a key risk factor. Long-term smoking contributes to the abnormal proliferation of bronchial mucosal epithelial cells. Up to 85% of lung cancer deaths can be attributed to smoking, and the risk of lung cancer caused by passive smoking should not be underestimated. Atmospheric pollution is also an important causative factor. Carcinogenic substances such as benzopyrene, contained in outdoor industrial and automobile exhaust, as well as formaldehyde and radon released by indoor decorative materials, increase the incidence of the disease³. In addition, chronic diseases of the lungs in the healing process, such as chronic inflammation of the lungs and bronchial tubes and fibrous scarring lesions of the lungs, may trigger squamous epithelial hyperplasia or hyperplasia, which in some cases then develops into carcinoma. Meanwhile, oncogenes and oncogene mutations, as well as family genetic history, immunocompromise, abnormal metabolic activity, and secretion dysfunction, are associated with the development of NSCLC^4,5,6.

The status of NSCLC patients varies depending on the disease. Most patients are diagnosed at an intermediate to advanced stage, which results in a lower 5-year survival rate⁷. Different types of NSCLC show dynamic changes in incidence, with an increasing proportion of lung adenocarcinoma and a gradual decrease in the proportion of squamous cell carcinoma⁸. In terms of symptomatic manifestations, cough is often seen in the early stage, mostly an irritating dry cough with no or little sputum, and the cough will be aggravated after the tumor causes bronchial stenosis. Blood in sputum or hemoptysis is more common in central lung cancer. Tumor growth into the lumen can lead to intermittent or persistent blood in sputum, and hemoptysis can be triggered by erosion of large blood vessels in severe cases. Shortness of breath or wheezing is also a common symptom. Tumor encroaching on airways or metastasizing to hilar lymph nodes and compressing the main bronchus can lead to dyspnea and wheezing, and a limited or unilateral rumbling sound can be heard on auscultation. Occasional vague chest pain also occurs, associated with tumor metastasis or direct invasion of the chest wall⁹.

NSCLC may cause a variety of complications. In central nervous system metastasis, brain metastasis can lead to symptoms of increased intracranial pressure such as headache, nausea, vomiting, and may also present with vertigo, ataxia, diplopia, personality changes, seizures, or hemiparesis with weakness of limbs; compression of the spinal cord bundle may present with back pain, weakness of the lower limbs, sensory abnormalities, and loss of bladder or bowel function. Skeletal metastasis manifests as localized pain, pressure pain, or even a pathological fracture, most commonly in ribs, vertebrae, the pelvis, and long bones of the limbs, and is often an osteolytic lesion. Abdominal metastasis may involve the liver, pancreas, and gastrointestinal tract, with symptoms of loss of appetite, pain in the liver area, abdominal pain, jaundice, hepatomegaly, abdominal fluid, pancreatitis, and adrenal metastasis is also more common^10,11. Therefore, it is important to manage and monitor the patients in a more refined manner.

Case management nursing (CMN) is a patient-centered model that integrates multidisciplinary resources to provide full, continuous, and personalized care to patients¹². It centers on coordinating healthcare professionals so that patients receive optimal care throughout the treatment process, from disease diagnosis and treatment to rehabilitation. Case managers play a key role in the CMN process. They are usually professionals with extensive medical and nursing knowledge and good communication and coordination skills. The process begins with a comprehensive assessment of the patient, including physical condition, psychological status, social support system, financial situation, and cultural background, with the aim of accurately identifying the patient's unique needs¹³. Based on the results of the assessment, a multidisciplinary team of CMN physicians, rehabilitation therapists, dietitians, psychologists, and other members of the team work together to develop a personalized care plan that defines the goals and interventions for each stage of care. The advantages of this care approach are significant. For patients, they can receive coherent and systematic care services, avoid delays or omissions caused by poorly connected medical links, enhance patients' confidence and compliance with disease treatment, and improve their quality of life. From the perspective of the healthcare system, CMN helps to optimize resource allocation, enhance healthcare service efficiency, reduce unnecessary medical expenditures, promote multidisciplinary collaboration, and improve the overall healthcare service level of the team^14,15.

Cognitive behavioral therapy (CBT) is a psychotherapeutic approach that combines cognitive and behavioral therapies to correct maladaptive cognitions and thereby eliminate maladaptive emotional and behavioral problems by altering the patient's patterns of thinking, beliefs, and behaviors. In nursing, the cognitive-behavioral therapy approach provides patients with systematic and effective psychological support and intervention strategies¹⁶. Its core principle lies in the fact that cognition influences emotions and behaviors, and negative, irrational cognitions can trigger negative emotions and undesirable behaviors¹⁷. CBT aims to identify and change these maladaptive cognitions and to guide patients in establishing a positive, rational way of thinking, thereby improving emotional states and correcting behavioral deviations¹⁸. According to Beck's cognitive model, individual cognition, emotion, and behavior interact with each other, and postoperative NSCLC patients often develop negative automatic thinking and cognitive misinterpretation, such as 'tumor is bound to recur' and 'there is no hope for recovery' due to the pressure of the disease. Through the three stages of 'identification - assessment - reconstruction' and the use of Socratic questioning, reality testing, and other techniques, CBT helps patients to transform negative cognition into rational cognition and break the vicious cycle of 'cognitive bias - negative emotion - behavioral withdrawal'¹⁹. Self-regulation theory stresses that individuals achieve behavioral change through goal setting, self-monitoring, and feedback regulation. In nursing practice, nursing staff assisted patients to refine their rehabilitation goals into specific tasks such as '10-minute daily breathing training', and instructed patients to record emotional diaries and behavioral logs to dynamically track psychological and behavioral changes. Based on the self-monitoring results, the patients adjusted their coping strategies and gradually improved their sense of self-efficacy, forming a positive cycle of 'cognitive optimization - behavioral improvement - emotional enhancement'²⁰.

During implementation, the cognitive behavioral therapy nursing approach involves several key steps. First, caregivers need to establish a good relationship of trust with patients, which is the basis for subsequent effective communication and intervention. Next, a comprehensive assessment is conducted to accurately identify patients' cognitive biases, emotional problems and behavioral abnormalities with the help of tools such as scale scores. Based on the assessment results, psychoeducation was carried out to explain the principles, methods, and expected effects of CBT, and to raise the patients' awareness of their own problems and treatment methods. At the same time, the patients were instructed to conduct self-monitoring and recording, such as recording daily mood changes, frequency of negative thinking, and triggering events, etc., to help the patients perceive their own problem patterns. Subsequently, nursing staff carried out behavioral skills training to help patients alleviate anxiety in response to their problems^21,22. In addition, they actively sought social support for patients, contacted family members and friends to give emotional care and practical help, and organized patient communication meetings so that patients could gain emotional resonance and experience in the group. Throughout the process, nursing staff continuously monitor and assess the patient's situation, and timely adjust the nursing program based on changes in condition and psychological status²³.

Therefore, in view of the treatment of CMN and CBT, this study observed the clinical efficacy of the combined use of the two in the treatment of NSCLC patients, analyzed the anxiety and depression and the quality of life of the patients after treatment, and clarified the effectiveness and safety of the combined use of the two treatments, so as to provide more therapeutic options for the clinic.

The study was performed in compliance with the Declaration of Helsinki and the hospital's ethical guidelines and was endorsed by the hospital's ethical committees (Ethics approval number: 2023003).

Study design:
This study was a single-center, non-randomized controlled study designed to systematically assess and integrate relevant outcomes, aiming to analyze the efficacy of the combination of CMN and CBT in the treatment of patients with NSCLC, and to further assess its impact on patients' anxiety and depression and quality of life. The study was evaluated by multidimensional measurement tools, before and after treatment, respectively, to ensure the completeness and accuracy of the data. Eighty-five NSCLC patients from the Hospital from May 2023 to January 2024 were enrolled in this study, and a total of 80 patients were included in the study after exclusion. Patients were allocated to the intervention groups based on the hospital ward to which they were admitted. During the study period, Ward A implemented case management (CM) as the standard of care, while Ward B piloted an integrated protocol combining case management with cognitive-behavioral therapy (CC). This allocation method was based on existing clinical practice and was not randomized. In order to compare and analyze the differences between the two nursing modes on the therapeutic effects and psychological status and quality of life of NSCLC patients, and to provide scientific basis for the clinical optimization of the nursing program for NSCLC patients. The flow chart of this study is demonstrated in Figure 1.

Inclusion and exclusion criteria:
The inclusion criteria were as follows: (1) The patient meets the clinical diagnostic criteria for NSCLC²⁴ and is classified as clinical stage IIIB or IV. (2) The patient has received chemotherapy. (3) The patient has not taken any hormone-containing drugs within six months prior to treatment initiation. (4) The patient is 20 years old or older. (5) The patient is able to truthfully report their symptom-related complaints and respond to relevant inquiries from medical staff. (6) The patient's expected survival time is more than 6 months. (7) The patient and their family members have been fully informed of the study details, expressed their consent to participate, and signed the informed consent form.

The exclusion criteria were as follows: (1) The patient has a malignant tumor of any other site or type. (2) The patient is complicated with hemorrhagic coagulation dysfunction, severe liver or renal function impairment, severe cardiovascular disease, or other serious comorbidities. (3) The patient is complicated with chronic infectious diseases. (4) The patient has participated in other clinical drug trials or clinical research projects. (5) The patient has cognitive dysfunction or comorbid neurological or psychiatric disorders that hinder normal communication. (6) The patient requests to discontinue treatment or withdraws from the study voluntarily for personal reasons. (7) The patient has other conditions that the study physician deems unsuitable for inclusion. (8) The patient has other circumstances that may interfere with the assessment of follow-up observation indicators.

Interventions:
Both groups of patients were treated with CMN. The specific methods were as follows.

Case management team preparation: An interdisciplinary case management team was formed, with core members including case managers, unit nurse managers, clinicians, nutrition specialists, pharmacists, ward nurses, and direct care nurses. The team provides comprehensive, personalized care to the patient through multidisciplinary collaboration. Team members discuss the patient's condition on a weekly basis and invite the patient and family to participate. Job responsibilities for team members are developed, and the case manager is responsible for training, communication, and coordination within the team, development of individualized intervention plans, data collection and analysis, program evaluation, and patient follow-up to ensure treatment adherence. Other personnel perform their respective duties to ensure supervision of the implementation of the program, treatment plan, nutritional intervention, and medication instruction, as well as health education and follow-up.

Case management team training: All team members receive relevant training covering case management theory, knowledge of tumor immunotherapy, the specific needs of lung cancer patients, and the teamwork process. After training, each member is ensured to have the qualification for induction through examination.

Implementation of the intervention program
Pre-admission management: Within 24 h prior to admission, the outpatient records were reviewed to get a preliminary understanding of the patient's basic situation. The case management mode was introduced to patients, and personal health records were established to lay the foundation for personalized care.

Admission management: The initial assessment and data collection of the patient were completed within 24 h of admission, and case care was implemented. The assessment included disease cognition, life satisfaction, physical health, social relationships, and assisted patients in identifying the focus of their problems, setting priorities, and planning goals.

Management during hospitalization: A comprehensive assessment was completed, and the patient was engaged to identify care priorities and goals. The case manager coordinated team resources, dynamically adjusted the care plan according to the patient's needs, ensured the patient's active participation in the treatment process, and discussed the patient's specific problems at weekly team meetings to adjust the care strategy when appropriate.

Pre-discharge management: The patient's condition was assessed, post-discharge care plans and follow-up arrangements were developed, and the patient was informed of the possible adverse effects of treatment.

Post-discharge management: Telephone follow-up was conducted after discharge, once in the first week and once every 2 weeks thereafter, with the frequency of follow-up gradually reduced as the patient's adverse reactions decreased or disappeared. The follow-up visits included the method and timing of medication intake, functional exercise and dietary regimens, implementation of the program, and records of adverse reactions. The follow-up information collected was fed back to the team and used for continuous improvement of the care plan. Monthly team meetings were held to review the effectiveness of case management and to make recommendations for improvement, and case managers fed back the results of the meetings to the patients and their families to form closed-loop management. All patients underwent outcome evaluations at two specific time points: before the initiation of treatment (baseline assessment) and at the 3-month follow-up after the completion of the continuous intervention.

CBT treatment was added to the CC group. The CBT intervention, based on Beck's cognitive therapy model²⁵, was conducted by a medical oncologist for 90 min per week for 12 weeks. The oncologist had completed a certified training program in CBT for anxiety and depression and received weekly supervision from a senior psychiatrist to ensure adherence to the model. While formal fidelity checks were not performed, structured session outlines were used to maintain consistency across interventions. The specific content of the intervention sessions was implemented with reference to established CBT protocols^26,27,28, with detailed procedures as follows:

i) Understanding cognitive status and establishing a therapeutic alliance: A 20-min semi-structured interview was conducted to assess patients' cognition of disease and treatment. The interventionist adopted an empathetic communication style to build trust and a collaborative partnership with patients.

ii) Reconstructing cognition: The intervention proceeded in three steps: (1) identifying automatic negative thoughts triggered by disease-related stressors; (2) labeling common cognitive distortions (e.g., catastrophizing, black-and-white thinking); (3) correcting distorted cognition via positive self-talk and adjusting extreme beliefs.

iii) Behavioral exercise: Two core components were included: (1) systematic relaxation training (20 min/session, 3 times/week, including diaphragmatic breathing and progressive muscle relaxation); (2) behavioral activation, namely developing personalized activity schedules to reduce avoidance behavior and build adaptive habits.

iv) Individualized psychotherapy: Based on anxiety/depression severity (assessed by SAS and SDS), 30-45 min one-on-one sessions were delivered weekly. The content focused on exploring emotional distress triggers and formulating targeted coping strategies.

v) Social support: A 30-min family education session was held to instruct family members to provide emotional validation and practical care, and to avoid negative remarks that may exacerbate patients' psychological burden.

Observational indicators:
Primary indicators
Anxiety and depression
The psychological stress of the patients before and after treatment was assessed separately. Hamilton anxiety scale (HAMA) assessed anxiety status, with a score of 7 to 14 indicating the possible presence of anxiety and a score of not less than 14 representing the definite presence of anxiety²⁹. The Hamilton Depression Scale (HAMD) assesses the state of depression, with a score of 7 to 17 indicating the possible presence of depression and a score of not less than 17 indicating the definite presence of depression, and the higher the score, the more severe the depression³⁰.

Self-perceived burden
The Self-perceived burden scale (SPBS) was used to evaluate self-perceived burdens, covering three dimensions of economic, emotional, and physical burdens, with a total score of 50, and higher scores indicated heavier self-perceived burdens³¹.

Quality of life
Compare the quality of life of both groups pre- and post-intervention. It was evaluated by using the quality of life measurement core scale for cancer patients (QLQ-C30), including five functional dimensions of emotion, somatic, social, role, and cognition, with a total score of 100 for each item, and the higher the score, the better the quality of life³².

Neurotransmitter levels
Patients' early morning fasting elbow venous blood was drawn and placed in sodium heparin anticoagulant tubes, and appropriate amounts of serum were taken for enzyme immunoassay to determine 5-hydroxytryptamine (5-HT) and brain-derived neurotrophic factor (BDNF)³³. The kits used were the human 5-HT ELISA assay kit and the human BDNF ELISA assay kit, respectively.

Clinical efficacy
Clinical efficacy was judged according to anxiety and depression scores. An obvious effect was defined as a decrease of ≥50% in the total HAMA score to <14 points and a decrease of ≥50% in the total HAMD score to <7 points. An effective response was defined as a 25%-50% reduction in the total HAMA score to between 14 and 21 points and a 25%-50% reduction in the total HAMD score to between 7 and 17 points. An ineffective response was defined as a decrease of <25% in the total HAMA score or a remaining score of ≥21 points, and a decrease of <25% in the total HAMD score or a remaining score of ≥17 points.

Secondary indicators
Pain level
The pain level of both groups pre- and post-treatment was compared. The visual analog scores (VAS) were used to assess the pain level, with a total score of 0-10, and higher scores indicated more severe pain³⁴.

Nursing satisfaction
To compare the satisfaction of both groups of patients with postoperative intervention nursing care, a self-made nursing satisfaction questionnaire was used to assess the four dimensions of professionalism, nursing operation, communication and attitude, with a total score of 25 for each dimension, and the higher the score, the higher the nursing satisfaction in that dimension.

Adverse reactions
The occurrence of adverse reactions during treatment was recorded in both groups, including wound pain, dyspnea, coughing, nausea/vomiting, hot flashes/sweating, headache, fatigue/weakness, easy to fall asleep, and anxiety.

Complications
Record the postoperative complications in both groups, including pneumonia, pneumothorax, pleural effusion, gastrointestinal bleeding, gastrointestinal perforation, respiratory tract infection, heart failure, wound infection, etc.

Follow-up visits
Follow-up visits at 3 months post-treatment were mainly arranged in this study to assess the durability of the effect and to deal with any potential adverse reactions or problems.

Sample size calculation
Sample size was calculated using G*Power 3.1.9.7 software. The calculation was based on the primary outcome of anxiety reduction, as measured by the HAMA score. Based on a previous pilot study, we anticipated a clinically significant difference between the groups. Assuming a two-tailed independent samples t-test with a medium effect size (Cohen's d = 0.65), an alpha level of 0.05, and a desired power of 80%, the required sample size was calculated to be 38 participants per group. To account for potential dropouts, we recruited 40 patients for each group.

Statistical methods
The outcome assessors were not blinded to the group allocation of the patients. SPSS 27.0 statistical software was used to analyze the data. The data in this study were tested for normal distribution. Baseline characteristics were described as the number of persons and variables (expressed as  ± s). HAMA, HAMD, SPBS, QLQ-C30, neurotransmitter levels, VAS scores, and satisfaction with care results were expressed as  ± s. Comparison between the two groups was examined using an independent samples t-test. Clinical efficacy, adverse effects, and complications in the results were expressed as proportions (%). Comparison between the two groups was analyzed using x² test. All statistical tests were two-sided, and P < 0.05 indicated a statistically significant difference. To control for the risk of Type I error due to multiple comparisons for the primary outcomes, a Bonferroni correction was applied, and the significance level was adjusted accordingly.

Basic information
In this study, 80 patients with NSCLC from May 2023 to January 2024 were categorized into the CM group (n = 40) and CC group (n = 40) depending on different interventions. The baseline demographic and baseline characteristics in the two groups are displayed in Table 1, and these characteristics were not significantly different between the groups (P > 0.05). Therefore, both groups were comparable at the pre-treatment level, and the confounding of demographic/clinical factors did not affect the analysis of the results.

Primary results
Anxiety and depressive mood
The results of anxiety and depressive mood of both groups of patients are demonstrated in Table 2. Pre-treatment, no marked differences were found in the anxiety and depressive mood in both groups (P > 0.05). Post-treatment, the HAMA and HAMD scores in both groups were significantly reduced (P < 0.05). The HAMA and HAMD scores of the CC group were 10.18 ± 2.10 and 11.94 ± 2.91, respectively, which were significantly lower than the CM group's 16.04 ± 3.89 and 16.81 ± 3.19, respectively (P < 0.001, Cohen's d = 1.89 for HAMA; P < 0.001, Cohen's d = 1.63 for HAMD). It indicates that the anxiety and depression of both groups improved post-treatment, and the CC group had a better improvement effect.

SPBS score
The SPBS score can reflect the subjective feeling of the patients' burden on their caregivers due to their own illnesses, and provide a basis for healthcare professionals to formulate personalized nursing interventions, improve the patients' psychological state, and enhance their life quality. The results of the SPBS scores of both groups are displayed in Table 3. Pre-treatment, no marked difference was found in the SPBS scores of both groups (P > 0.05). Post-treatment, the scores of patients in both groups were decreased significantly (P < 0.05). The score in the CC group was 25.52 ± 3.17, significantly lower than the score of 33.50 ± 5.61 in the CM group (P < 0.05). It shows that both treatments can improve the psychological burden of patients, and the CC group has better improvement.

Life quality
We observed the quality of life of the patients, and the results are presented in Table 4. Pre-treatment, no obvious differences were found in the QLQ-C30 scores of both groups of patients (P > 0.05). Post-treatment, the scores of patients in both groups were significantly increased (P < 0.05). The five function scores of CC group patients were 64.76 ± 4.39, 68.41 ± 3.63, 71.09 ± 3.99, 66.69 ± 4.59, 66.13 ± 4.61 for emotional, somatic, social, role, and cognitive, respectively, which were higher than the 59.41 ± 4.97, 62.28 ± 3.78, 64.41 ± 3.97, 61.27 ± 4.70, 59.67 ± 4.96 in the CM group, respectively (P < 0.05). These results indicated that the patients' quality of life improved in both groups post-treatment, and the CC group improved significantly better. In terms of cognitive functioning, CBT corrects cognitive biases such as catastrophic thinking and overgeneralisation through cognitive restructuring and Socratic questioning, reduces psychological stress and anxiety-induced attention and memory problems, and enhances cognitive functioning by strengthening neuroplasticity with the help of self-regulation training. In terms of social functioning, the behavioral intervention of CBT combines with social support theory, and through exposure therapy, role-playing, and other behavioral training, it helps patients to overcome social fear, enhance their social confidence and self-efficacy, and improve interpersonal relationships. In addition, the synergy between CBT and CMN guarantees the long-term accessibility of the intervention, enhances patients' rehabilitation compliance and self-management ability, and amplifies the effect of quality of life improvement. The results validate the effectiveness of CBT theory in psychological intervention for postoperative NSCLC patients and provide a theoretical basis for clinical care.

Neurotransmitter levels
Changes in neurotransmitter levels are important reference indicators for assessing the development of psychiatric and psychological disorders and certain neurological disorders. 5-HT is widely distributed in the central nervous system and is deeply involved in emotion regulation, cognitive function, and sleep-wake cycle regulation. When the level of 5-HT decreases, the activity of γ-aminobutyric acidergic neurons is inhibited, and the excitability of the brain is enhanced, which easily induces negative emotions such as anxiety and depression, and leads to cognitive dysfunctions such as inattention and memory loss. BDNF is mainly expressed in the central nervous system and is significant for neuronal survival, differentiation, synaptic plasticity, and nerve regeneration. In terms of psychological regulation, BDNF activates TrkB receptors, enhances neuronal connectivity, and promotes neuroplasticity. Under stress or negative emotional state, BDNF expression is suppressed, triggering synaptic structure and function abnormalities, and exacerbating anxiety and depression; on the contrary, elevated levels of BDNF can repair synapses and improve cognition and emotional state.

The results of comparing the neurotransmitter levels of both groups of patients are presented in Table 5. Pre-treatment, no significant differences were found in the neurotransmitter levels of both groups of patients (P > 0.05). Post-treatment, the scores of patients in both groups were significantly increased (P < 0.05). The levels of 5-HT and BDNF in the CC group were 250.25 ± 23.71 ng/mL and 1496.23 ± 244.02 pg/mL, respectively, which were significantly higher than the CM group's 209.80 ± 22.97 ng/mL and 1277.32 ± 277.38 pg/mL (P < 0.05). It indicates that the treatment methods in this study played a positive role in improving the neurological function and psychological state of the patients, and the CC group had a better improvement effect. The combination therapy in this study corrects patients' negative thinking, reduces anxiety and depression, restores the balance of the neuroendocrine system, and promotes the synthesis and release of 5-HT. Behavioral training and self-regulation strategies activate the brain reward system and increase the expression of BDNF, forming a virtuous cycle of 'psychological improvement - neurotransmitter regulation - enhancement of neurological function - further improvement of psychological state', thus realizing the dual optimization of the patients' neurological and psychological states.

Clinical efficacy
In combination with the therapeutic effect, we analyzed the clinical efficacy of both patient groups; the results are presented in Table 6. The total effective rate of the CC group patients was 90.00% (36/40), and the CM group was 75.00% (30/40), showing marked differences compared with the groups (P < 0.05). The results showed better efficacy of the CC group patients, indicating better clinical efficacy of combined treatment.

Secondary results
VAS score
The VAS scores of both groups of patients are demonstrated in Table 7. Pre-treatment, no marked differences were found among the scores of both groups of patients (P > 0.05). Post-treatment, the score of patients in the CC group was 2.74 ± 0.37 and 5.07 ± 0.93 in the CM group, which was significantly lower than in the CC group (P < 0.05). It indicated that the pain levels of both groups improved after treatment, and that the CC group patients experienced better pain relief.

Nursing care satisfaction
Comparing the two groups of patients' nursing satisfaction with the postoperative intervention treatment in this study, the results of the questionnaire are displayed in Table 8. There were significant differences between the groups in satisfaction with four aspects, including the professionalism of the nursing staff and nursing operations, and patients in the CC group had higher satisfaction scores for all nursing care than those in the CM group (P < 0.05). This indicates that patients in the CC group were very satisfied with the combined treatment program.

Adverse reactions
We followed up with the patients to observe the adverse reactions. The patients in both groups experienced adverse reactions of varying degrees, such as wound pain during treatment, as indicated in Table 9. No remarkable discrepancy was found in the comparison of both groups of patients who developed adverse reactions, such as trauma pain (P > 0.05). The total incidence of adverse reactions in patients of the CM group was 15.00% (6/40), which was significantly higher than 5.00% (2/40) in patients of the CC group (P < 0.05). It indicated that the therapeutic effect of the treatment used in the CC group patients was better and safer.

Complications
Complications, including pneumonia and pneumothorax, occurred in both groups, and the results are presented in Table 10. No significant difference was found between the groups when compared with the group that developed complications such as pneumonia (P > 0.05). The total complication rate of patients in the CC group was 7.50% (3/40), significantly lower than that of 17.50% (7/40) in the CM group (P < 0.05). It indicates that the combined treatment can effectively reduce the incidence of complications.

DATA AVAILABILITY:
The raw data have been uploaded as a supplementary file (Supplementary File 1).

Figure 1: Flow chart. This flow chart depicts the screening, enrollment, and grouping process of 80 NSCLC patients (recruited from May 2023 to January 2024) into the CM group (n=40, CMN treatment) and CC group (n=40, CMN plus CBT treatment) for comparing nursing efficacy, psychological status, and quality of life. Please click here to view a larger version of this figure.

Table 1: Patient demographics and baseline disease characteristics. This table presents the baseline demographic and clinical characteristics of the two groups, confirming no significant between-group differences (P>0.05) and thus verifying group comparability. Please click here to download this Table.

Table 2: Anxiety and depressive mood ( ± s, score). This table shows that both groups had reduced HAMA and HAMD scores after treatment, with the CC group exhibiting significantly lower scores than the CM group (P<0.05), indicating a superior effect on alleviating anxiety and depression. Note: "*" represents significant differences compared with pre-treatment, P<0.05. Please click here to download this Table.

Table 3: SPBS score ( ± s, score). This table displays the SPBS scores of the two groups, revealing a significant post-treatment reduction in both groups and a notably lower score in the CC group than in the CM group (P<0.05). Please click here to download this Table.

Table 4: QLQ-C30 score ( ± s, score). This table reports the QLQ-C30 quality of life scores, showing that all functional domain scores increased after treatment in both groups, with the CC group achieving significantly higher scores than the CM group (P<0.05). Note: "*" represents significant differences compared with pre-treatment, P<0.05. Please click here to download this Table.

Table 5: Neurotransmitter levels ( ± s). This table compares the 5-HT and BDNF levels of the two groups, demonstrating a significant post-treatment elevation in both neurotransmitters and significantly higher levels in the CC group than in the CM group (P<0.05). Note: "*" represents significant differences compared with pre-treatment, P<0.05. Please click here to download this Table.

Table 6: Clinical efficacy analysis. This table summarizes the clinical efficacy, showing that the total effective rate of the CC group was significantly higher than that of the CM group (P<0.05). Please click here to download this Table.

Table 7: VAS score ( ± s, score). This table presents the VAS pain scores, indicating no significant pre-treatment difference between groups and a significantly lower post-treatment score in the CC group than in the CM group (P<0.05). Please click here to download this Table.

Table 8: Nursing care satisfaction (± s, score). This table shows the nursing satisfaction questionnaire results, revealing that the CC group scored significantly higher than the CM group across four evaluation aspects (P<0.05). Please click here to download this Table.

Table 9: Adverse effects incidence [n(%)]. This table records the adverse reaction incidence, showing no significant difference in individual reaction types between groups, but a significantly lower total incidence in the CC group than in the CM group (P<0.05). Please click here to download this Table.

Table 10: Complications [n(%)]. This table compares the complication incidence, demonstrating no significant difference in individual complication types between groups and a significantly lower total incidence in the CC group than in the CM group (P<0.05). Please click here to download this Table.

Supplementary File 1: Raw data of this study.Please click here to download this File.

NSCLC, as the most common type of lung cancer, accounts for about 80% of all lung cancer patients. NSCLC covers a wide range of pathological types, such as squamous, adenocarcinoma, and large-cell carcinoma, and there are significant differences in biological behavior, treatment response, and prognosis among different types³⁵. The clinical presentation of NSCLC patients varies depending on the stage of the disease. In the early stage, patients may have no obvious symptoms or only mild cough, sputum, and other symptoms similar to respiratory tract infections, which can be easily overlooked. As the disease progresses, symptoms such as hemoptysis, chest pain, shortness of breath, fever, and weight loss may appear. When tumor metastasis occurs, the symptoms of the corresponding metastatic site will also appear, such as brain metastasis can cause headache, dizziness, vomiting, limb weakness, and other neurological symptoms; bone metastasis can lead to bone pain, pathological fracture, etc., which is a serious threat to human health^36,37.

In recent years, CMN has gained prominence in cancer care. The model consists of a professional case manager who provides comprehensive, continuous, and personalized care to the patient. The case manager is involved from the beginning of the patient's diagnosis and is responsible for coordinating the multidisciplinary team to develop the best treatment plan for the patient³⁸. During the treatment process, the patients' condition changes were closely monitored, and various adverse reactions and complications were handled in a timely manner. At the same time, patients in the intervention group had a significantly higher level of disease-related knowledge, and were able to understand more clearly the characteristics of their own disease, treatment methods, and precautions, which helped to enhance the patients' confidence in treatment and improve their self-management ability, thus improving their quality of life³⁹. CBT also plays an important role in lung cancer treatment. Cancer patients often suffer from anxiety, depression, and other adverse emotions due to long-term suffering from the disease, concerns about the prognosis of the disease, and the financial burden brought by the treatment, and these negative emotions can seriously affect the patient's therapeutic effect and quality of life^40,41. CBT relieves adverse emotions by helping patients identify and change negative thinking patterns and behavioral habits. Nursing staff will have in-depth communication with patients to guide them to recognize their irrational cognition, such as excessive fear of the disease and the belief that treatment is hopeless, etc., and help them rebuild positive cognition by providing scientific knowledge about the disease and successful treatment cases⁴². At the same time, patients were instructed to conduct relaxation training, time management, and other behavioral skills training to cope with the stress caused by the disease, which in turn improved the overall treatment effect and quality of life. Therefore, this study analyzed the effects of nursing intervention of CMN combined with CBT on anxiety and depression and quality of life of postoperative NSCLC patients, providing a new way for comprehensive treatment of patients⁴³.

The results of this study showed that after treatment, the indicators of the two groups of patients were statistically significant compared with those before treatment. HAMA and HAMD scores can quantitatively assess the severity of patients' anxiety and depression symptoms, providing an important reference basis for the diagnosis, differential diagnosis, and judgment of the degree of psychiatric diseases⁴⁴. SPBS can dynamically assess the changes in patients' psychological status, provide a key basis for timely adjustment of nursing care and interventions, and effectively improve patients' mental health and quality of life⁴⁵. QLQ-C30 quantitatively assesses five functional dimensions, including mood, which can comprehensively and intuitively reflect the quality of life of cancer patients, provide a key basis for healthcare professionals to understand the physical and mental state of patients, and timely adjust the treatment and care strategies to effectively improve the quality of life of patients⁴⁶. This study demonstrated that the HAMA score, HAMD score, and SPBS score of the CC group were significantly lower than those of the CM group, and the QLQ-C30 score was significantly higher than that of the CM group (P < 0.05). It indicated that after treatment, the anxiety and depression symptoms, psychological burden situation, and quality of life of patients in both groups improved, and the CC group patients who underwent nursing intervention of CMN combined with CBT had better improvement. 5-HT and BDNF levels play a key role in regulating mood, cognition and neuroplasticity, and their fluctuations reflect the health status of multiple systems, such as mental and neurological, and provide a basis for early diagnosis of diseases⁴⁷. The results indicated that the 5-HT level, BDNF level, and clinical efficacy of the CC group were significantly higher than those of the CM group (P < 0.05). It indicated that post-treatment, the neurotransmitter levels of patients in both groups improved, with better improvement in the CC group. In a study exploring the effects of CBT on anxiety, depression, and quality of life in lung cancer patients, Sutanto et al. noted that after CBT intervention, patients' anxiety and depression scale scores were significantly reduced, while their quality of life was significantly improved⁴⁰, which is consistent with the findings of this study.

The efficacy mechanism of CBT is analysed in depth from psychological theories, which integrate cognitive and behaviorist theories. Cognitive theory emphasises the cognitive processes of the individual, which have a decisive influence on mood and behavior. Behaviorist theory, on the other hand, focuses on individual behavioral performance and its interaction with the environment. In NSCLC patients, CBT works by altering the patient's cognitive model of the disease and their condition. When patients are confronted with the reality of the disease in conflict with their original perceptions, they can fall into a state of psychological discomfort. CBT can guide patients to identify negative thinking and help them to challenge these irrational beliefs, for example, by presenting objective evidence such as surgical records and postoperative examination results, so that patients can realize that their concerns are not based on reality, and thus correct their cognitive biases. When the patient's cognition gradually improves, the mood also improves, and the symptoms of anxiety and depression can be alleviated. The principle of operant conditioning in behaviorist theory is also reflected in CBT. During CBT intervention, whenever the patient successfully challenges negative thinking and engages in positive behaviors, such as taking the initiative to do rehabilitation exercises and facing the disease with an optimistic mindset, it can be considered a form of 'positive reinforcement'. This positive reinforcement increases the frequency of positive behaviors and further strengthens the positive cognitive and behavioral patterns, forming a virtuous circle. At the same time, the change of behavior in turn affects cognition and emotion, and in the practice of positive behavior, the patient's cognition of his own ability is improved, self-confidence is enhanced, and the emotional state is further improved.

The VAS score is used to determine the effectiveness of treatment measures in relieving pain by visually quantifying the degree of pain in patients, which helps to adjust the treatment plan in a timely manner. The results showed that the VAS scores of patients in the CC group were significantly lower than those of the CM group (P < 0.05). It indicated that the pain levels of patients in both groups were relieved after treatment, and that the pain relief in the CC group after combined treatment was better. In addition, we compared the nursing satisfaction of both groups of patients with the combined nursing intervention and CMN intervention alone in this study. There were marked differences in the satisfaction of both groups in four aspects, including the professionalism of the nursing staff and the nursing operation. The patients in the CC group had a better score of satisfaction with all nursing care than the CM group (P < 0.05). The results indicated that patients in the CC group were very satisfied with the combined intervention program, which may be related to postoperative rehabilitation and patients' subjective factors. The results of this study indicated that the incidence of adverse reactions and complications was lower in the CC group versus the CM group (P < 0.05). Similar findings were reported by Liu et al. in a study on the effect of CBT on glioma patients receiving chemotherapy⁴⁸. These results suggest that the nursing intervention of CMN combined with CBT can improve the impact of anxiety and depression and quality of life in NSCLC patients, and can effectively reduce complications and adverse effects, which is worth further promotion and application in clinical practice.

Despite the promising findings, this study has several limitations that must be acknowledged. A major limitation of this study is its non-randomized design, which introduces a potential risk of selection bias. Although baseline characteristics were comparable between the groups, unmeasured confounding variables may have influenced the outcomes. The lack of blinding for outcome assessors could introduce performance and detection bias, particularly for subjective measures such as the HAMA and HAMD scales. For example, patients' lifestyle and psychological state. The present study was a single-center study, which has a significant impact on the generalisability of the findings. The single-center study included only patients from a specific healthcare facility, and the facility's patient population is relatively homogeneous in terms of geography, economic status, and healthcare resource use, which is not representative of the broader characteristics of NSCLC patients. The results of the study are difficult to generalise and apply. In addition, due to the short follow-up period, it is not possible to comprehensively assess the long-term effects and safety of the treatment. Rehabilitation of NSCLC patients is a long-term process, and the long-term effects of nursing interventions may emerge gradually over time; it is difficult to determine whether new complications or adverse reactions will occur. Additionally, the CBT intervention lacked formal fidelity checks, which, despite the use of structured outlines and supervision, may limit the replicability of our findings. Finally, while a Bonferroni correction was applied to the primary outcomes, no such adjustment was made for the multiple secondary outcomes, meaning these exploratory findings should be interpreted with caution.

From a clinical perspective, the results of this study suggest that integrating structured psychological interventions such as CBT into routine case management is a feasible and effective strategy. This finding is particularly important for oncology nursing practice, as it indicates that nurses, with appropriate training and supervision, can play a key role in delivering psychological support. This approach could help build a more holistic and comprehensive cancer support system, ultimately improving the mental health and quality of life for postoperative NSCLC patients.

Based on this, it would be appropriate for follow-up studies to further expand the sample size to cover patients from different regions with different characteristics. Extend the follow-up period to comprehensively track the recovery process of patients. A multicenter study design should be adopted to improve the representativeness and generalizability of the results, so as to more comprehensively assess the efficacy and safety of nursing interventions combined with CBT for CMN. Future research should aim to replicate these findings in larger, multicenter prospective studies to strengthen the evidence and improve generalizability.

This study analyzes the nursing intervention of CMN combined with CBT on anxiety and depression and the quality of life of postoperative patients with NSCLC, in order to provide a new reference basis for the treatment of this type of disease. The results demonstrated that after CBT treatment, the patients' anxiety and depression and quality of life improved, while reducing the incidence of complications and adverse reactions, providing a scientific foundation for the clinical management of related diseases. However, its limited sample size and short follow-up period restrict the ability to assess the long-term efficacy of the treatment. Future research should involve multicenter, large-scale, and high-quality clinical trials to validate these findings.