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

Summary

Here, we analyze the impact of a nursing intervention of case management (CM) combined with cognitive-behavioral therapy (CBT) on anxiety and depression and quality of life in postoperative non-small cell lung cancer (NSCLC) patients.

Abstract

Non-small cell lung cancer (NSCLC) is characterized by high morbidity and lethality, causing a great physical and psychological burden on patients. Therefore, effective treatment of NSCLC patients is very important.

This study analyzes the impact of a nursing intervention of case management combined with cognitive-behavioral therapy on anxiety and depression and quality of life in postoperative NSCLC patients. A single-center, non-randomized controlled study in which 80 NSCLC patients from the Hospital were enrolled from May 2023 to January 2024, and were categorized into case management (CM) and cognitive-behavioral therapy (CBT) groups depending on treatment modalities, with case management care in both groups, and cognitive-behavioral therapy care added to the CM combined with CBT (CC) group.

The Hamilton anxiety scale (HAMA), Hamilton depression scale (HAMD), self-perception burden scale (SPBS), life qualities (QLQ-C30), neurotransmitter levels, and clinical effectiveness were primarily assessed in both groups post-treatment. Secondary outcomes included pain level (VAS score), nursing satisfaction, adverse events, and complications.

After treatment, the indicators of both groups were significantly different from those of the pre-treatment. Post-treatment, the CC group demonstrated significantly lower scores than the CM group in HAMA (10.18 ± 2.10 vs. 16.04 ± 3.89), HAMD (11.94 ± 2.91 vs. 16.81 ± 3.19), and SPBS (25.52 ± 3.17 vs. 33.50 ± 5.61) (all P < 0.05). Conversely, the CC group showed significantly higher QLQ-C30 scores and levels of 5-hydroxytryptamine (5-HT) and brain-derived neurotrophic factor (BDNF). The nursing intervention of case management combined with cognitive behavioral therapy has a good improvement effect on the anxiety and depression status of NSCLC patients. It can improve the quality of life, which is worth promoting and using in the clinic.

Introduction

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.

Protocol

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.

Results

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 confo...

Discussion

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, sputu...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Human 5-HT ELISA assay kit	Shanghai COIBO Bio-Technology Co Ltd.	CB10030-Hu
Human BDNF ELISA assay kit	Shanghai COIBO Bio-Technology Co Ltd.	CB12019-Hu