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Abstract

Background:

Colorectal cancer (CRC) imposes a heavy disease burden. Besides physical morbidity, some patients might still experience long-term psychological distress. Our previous study demonstrated that physical symptoms and psychological distress of CRC improved following traditional Chinese medicine (TCM) combined online group psychotherapy. However, the multidimensional nature of these experiences warrants deeper exploration of patients’ lived perspectives.

Methods:

We designed a single-arm phase I clinical trial, in which 40 CRC patients (aged between 18 and 75) who have received radical surgery (stage I-III) were recruited. This 6-week intervention of TCM combined online group psychotherapy included 90 minutes’ communication on various topics for each week. The video of each online group psychotherapy session was saved, and the 38 patient’s’ speech was analyzed by thematic analysis in the qualitative study.

Results:

We identified 4 themes and 13 subthemes. The patients mainly displayed foundational outlook transformation and tangible lifestyle reformation. The physical symptoms and psychological symptoms also had a certain degree of relief. In addition, patients also showed an increased demand for medical advice and health care information, which indicates that they were more concerned about their health condition, and the needs of patients were responded to in treatment, resulting in corresponding benefits.

Conclusion:

During TCM combined online group psychotherapy interventions—including education, skill-building, TCM lifestyle coaching, and peer-exchange platforms—patients developed sustained self-health management practices, improving psychological resilience and physical symptoms. This holistic, tailored and culturally sensitive approach fostered long-term recovery and independence of CRC survivors.

Keywords

colorectal neoplasms traditional Chinese medicine group psychotherapy qualitative research quality of life

Introduction

Colorectal cancer (CRC) imposes a heavy disease burden, ranking as the third most common cancer worldwide in terms of incidence and the second highest in terms of mortality.¹ In 2022, 1,926,118 new cases were reported globally, and 903,859 deaths were attributed to CRC.¹ Timely screening, early diagnosis, and proactive intervention can significantly improve patient survival and improve prognosis.^2,3 However, besides physical morbidity, some patients might still experience long-term psychological distress, such as anxiety, depression, and fear of cancer recurrence, even after radical cancer treatment.^4
-7 Psychological distress adversely affects patients’ quality of life and disease prognosis.^8
-11 This has led to the recommendation of implementation of cancer survivorship care in many countries and International organizations.^12
-15 These focus on monitoring and managing symptoms with the aim of promoting health and preventing recurrence after the acute phase of treatment.^16,17

In recent years, integrative medicine has been increasingly used to support the psychological well-being of cancer survivors.^18
-20 As a vital component of integrative medicine, traditional Chinese medicine (TCM) exemplifies how traditional knowledge systems can complement modern medicine, offering a culturally sensitive approach to healing that honors the heritage of Chinese patients while addressing their individual needs.²¹ Our previous research has also shown that Chinese cancer survivors’ perceived needs for survivorship care are positively correlated with their willingness to use TCM.²² TCM embraces views on life and death, values both the beginning and end, and fosters a professional ethos of compassion and humility. In clinical practice, TCM practitioners use information gathered through 4 diagnostic methods (inspection, auscultation, inquiry, and palpation) to identify various patterns of disharmony in patients. They then provide targeted treatments using methods such as herbal medicine ingestion, herbal fumigation, herbal bathing, moxibustion, acupuncture, massage, acupressure, qigong, and TCM five-element music therapy (TCM-FEMT).²³ Studies have shown beneficial adjunctive effects in improving survival rates, alleviating physical symptoms, enhancing quality of life, and reducing levels of depression.^24
-27 However, there is still a lack of clinical research that combines TCM with psychological intervention to support the rehabilitation of CRC survivors.

Therefore, our team developed a 6-week TCM combined online group psychotherapy intervention (Table 1), which included 90 minutes of communication on psychological counseling, mindfulness practice, physical symptom management, TCM lifestyle and self-management coaching, self-acupressure guidance, and health care exercises. Since 2020, we have used this intervention in a pilot phase I clinical trial on CRC survivors to study its feasibility and effectiveness in managing psychological distress and regulating the gut microbiome of CRC survivors. Results from the single-arm trial²⁸ demonstrated that during the 6-week intervention, patients exhibited significant reductions in psychological distress—including perceived depression, anxiety, and fear of cancer recurrence—measured by validated scales (Self-rating Anxiety Scale, SAS; Self-rating Depression Scale, SDS; Fear of Cancer Recurrence Inventory, FCRI). Although the overall Quality of Life Questionnaire (QLQ-C30) showed no statistically significant improvement, directional improvements were observed in role, emotional, cognitive, and social functions. Concurrently, physical function remained stable without significant clinical changes, whereas insomnia and fatigue symptom burdens demonstrated statistically significant alleviation. These quantitative outcomes confirm the intervention’s effectiveness in alleviating psychological distress and specific symptom burdens among CRC survivors.

Table 1.

Framework of the 6-Week TCM Combined Group Psychotherapy Intervention.²⁸

Week	Theme	Contents	TCM guidance	Psychology skills	The topics of supportive expression
1	Nice to meet you!	Introduction on the aim and rules of the program; self-introduction among group members.	What is harmony between the mind and body and why is it important for cancer rehabilitation?	Mindfulness practice on breath; supportive expression	a. Recent circumstances on both physical and mental state; b. What do you expect our group to help you to deal with? Are there any requirement?
2	How can we manage our symptoms?	Introduction to lifestyle modification after colorectal cancer diagnosis and self-symptom management methods.	TCM guidance on diet, exercise, self-massage and foot bath for insomnia, bowel disfunction, and CIPN.	Patient education; cognitive behavioral therapy intervention; supportive expression	a. Recent circumstances on both physical and mental state; b. Are there any worries you have? c. Are you willing to / have you ever try the practices that we taught you last week? Is it a good or bad experience during the practices? d. Please share your effective methods you’ve tried to deal with your physical symptoms.
3	How can emotions be managed?	Guide patients in expressing their worries about cancer and fear of cancer recurrence and educate them on emotional and stress management.	Introduce acupoints for emotional relaxation and acupressure methods.	Concentration practice; psychological education; supportive expression	a. Recent circumstances on both physical and mental state; b. Have you ever adjust your daily life, such as diet, exercises, mental state or anything else? c. During our practice, whether you feel relax and concentrate or hard to continue?
4	How can we be friends with our bodies?	Guide patients to pay attention to their body and try to communicate with it.	Introduce acupoints for self-symptom management and methods of acupressure.	Mindfulness practice on body scan; cognitive behavioral therapy; supportive expression	a. Recent circumstances on both physical and mental state; b. Have you ever though about being a friend of your body? c. If your body is your friend, what do you want to say to him or hThankfulness or something else? d. Do you want to talk with your whole body or one organ?
5	How can we support our family and loved ones?	Guide patients to share any changes in their family and social support after cancer diagnosis; List the five most important things in one’s life.	How can one find support from family or friends and give them support according to their Chinese social culture background?	Mountain meditation; psychological education; supportive expression	a. Recent circumstances on both physical and mental state; b. Who is the important member that you want to thank to? Is he/she your family member or your friend or both of them. c. Why do you both treasure each other? d. Please share your story you remember the most with them, If you are willing to.
6	How can we plan our future? Farewell!	Guide patients to write their own lucky diary and address any needs that have not been met.	Conclude TCM guidance on health promotion and answer some individualized questions.	Mindfulness practice on love; supportive expression	a. Recent circumstances on both physical and mental state; b. why you consider those five values as the important things in your life? c. Please share your future plan.

Abbreviations: CIPN: Chemotherapy-induced peripheral neuropathy.

However, psychological distress and physical symptoms are multidimensional and deeply personal. To gain a richer understanding of the intervention’s value beyond quantitative measures, we conducted this secondary qualitative analysis to explore colorectal cancer survivors’ lived experiences and perceived meaning derived from participating in the TCM combined online group psychotherapy program. Specifically, we aimed to describe the range of patients’ perspectives, behavioral changes, and overall experiences encountered during the intervention process.

Methods

Design

This qualitative research design was employed to characterize patients’ lived experiences throughout the TCM combined group psychotherapy intervention, capturing their multifaceted perspectives on symptom management and emotional adaptation processes. Data were collected during group psychotherapy through video recording and analyzed by thematic analysis methods.

This study was nested within a single-arm clinical trial (register number: ChiCTR2000041247). The Ethics Board of Xiyuan Hospital approved this study protocol (2020XLA048-2). Prior to data collection, all participants provided written informed consent explicitly authorizing video-recording of sessions for clinical analysis. The transcripts underwent rigorous removal of personal identifiers to achieve external non-identifiability. The reporting of this study was guided by the Standards for Reporting Qualitative Research.²⁹

Sample and Setting

The study was conducted in 2 tertiary centers in China. The inclusion criteria were as follows: (1) patients with CRC with a pathological diagnosis; (2) TNM I-III stage disease and having received radical resection (R0 resection); and (3) age 18-80 years, either gender. The exclusion criteria were as follows: (1) occurrence of local or distant metastasis; (2) inability to understand and communicate in Chinese; and (3) previous diagnosis of serious mental disorders or psychosis by a licensed psychiatrist or administration of anti-anxiety and depressive drugs. As a phase I clinical trial, the sample size was defined as 40 patients to explore feasibility and preliminary efficacy.

Data Collection

Data were primarily collected from patient sharing during the group intervention by 2 physicians who had been trained in qualitative methodology. The data were derived from supportive expressions (Table 1) during group psychotherapy. The 6 sessions covered different fixed topics, and supportive expression was used in the discussions related to these topics. The main topics discussed included self-introduction, purpose and expectations of participating in activities, recent circumstances, changes in lifestyle before and after the illness, family support, friend support, values, and future life plans. The determination of sample size for this qualitative research was based on the concept of saturation, which indicates that no further new information or topics can be obtained from the collected data, thus ensuring the adequacy and representativeness of the sample.

Data Analysis

Guided by a constructivist paradigm, we analyzed the data using thematic analysis following the 6 phases described by Braun and Clarke.³⁰ After each communication, the video recordings were transcribed verbatim. Next, 2 independent researchers carefully analyzed the manuscript by rereading the transcripts line by line, focusing on the respondents’ physical and mental states since the onset of illness and taking note of their initial thoughts. They independently generated initial codes through grouping notes about commonalities in the transcripts and classifying meaningful thoughts. Subsequently, they organized relevant data points, extracted associated themes, and grouped the data according to overall themes using the collected codes for interpretive analysis. After comparing their findings, they discussed and refined the code list and potential themes. This included reviewing, analysing, and refining the identified themes, merging those with significant similarities. The researchers then organized the codes into categories that were further grouped into subthemes and overarching themes based on similarities, differences, relationships, and patterns. Finally, the characteristics of each theme were refined by reanalysing a subset of representative themes, and the results were presented to all researchers for feedback. This iterative process involved frequent discussions and adjustments to ensure consensus.

As outlined by Lincoln and Guba, the criteria for rigor were credibility, transferability, dependability, and conformability.³¹ To achieve credibility, we established a research team with all investigators who possessed adequate knowledge and skills to accomplish their roles. Transferability was improved because the participants were selected to ensure a heterogeneous sample with various demographic characteristics, and the researchers used open-ended questions to conduct in-depth interviews. Dependability was achieved by 2 researchers independently analyzing the data, and all authors joined the discussion to reach a consensus. Conformability was guaranteed by the researchers following the thematic analysis process with no prejudice.

Results

After enrolling 40 patients, 2 patients ultimately withdrew from the study. Among the 38 patients included in the final analysis, the number of those over 60 years old was equal to the number of those aged 60 or younger; the mean age of the patients was 58 ± 13 years, with 24 (63.2%) males and 14 (36.8%) females. The tumor sites included the right colon (9 cases, 23.7%), left colon (9 cases, 23.7%), and rectum (20 cases, 52.6%; Table 2). At the time of enrollment, patients’ pathological cancer stages spanned from stage I to stage III, with 23.7% still undergoing active treatment, while the others were in the follow-up phase.²⁸

Table 2.

Patient Characteristics.²⁸

Information		n%
Age (y)	≤60	19	50.0
	>60	19	50.0
Sex	Male	24	63.2
	Female	14	36.8
Stage	I	4	10.5
	II	8	21.1
	III	26	68.4
Tumor site	Right colon	9	23.7
	Left colon	9	23.7
	Rectum	20	52.6
Treatment status	Active cancer treatments	9	23.7
	Follow-up	29	76.3
Time since surgery	≤6 months	12	31.6
	6-12 months	10	26.3
	>12 months	16	42.1

Based on the data analysis, we identified 4 themes and 13 subthemes (Table 3). Each theme was defined according to the original data, and the most representative descriptions are listed following each theme.

Table 3.

Illustrative Quotes of 13 Subthemes.

Theme	Subtheme	Illustrative quotes
Foundational outlook transformation	Seeking positive emotions proactively	Quote 1: “Emotions are indeed crucial; it is better to tell ourselves that we are relatively healthy in terms of psychological cues, as opposed to feeling like there is an issue . . . I think portraying myself as a normal person and living a healthy and happy life are essential. Regardless of our future circumstances, approaching life with a positive attitude is the first step.” (Patient 18)
	Valuing life	Quote 2: “After getting sick, I feel that health is the most important thing, and everything else is secondary. I do not think money, honor, or unnecessary things in life are important to health.” (Patient 32)Quote 3: “My current goal is to survive for the next 5 years . . . At the end of these 5 years, I will be around 80 . . . extending beyond that would be a bonus. Specifically, it involves maintaining regular checkups, taking prescribed medications as directed by my physician, and being diligent in this regard. I am pretty much following through with these steps now.” (Patient 2)
	Tranquilized mind and empty thinking	Quote 4: “In the past, I have indeed spent a lot of time pursuing wealth and a stress-free life. I thought it was something I valued. It has also consumed a significant amount of my time . . . looking back . . . I realize it was meaningless.” (Patient 19)Quote 5: “Being close to nature is important to me; when surrounded by nature . . . it has a profound impact on my mood . . . In the presence of mountains and water, I feel that everything suddenly becomes insignificant, and many concerns seem less important.” (Patient 32)Quote 6: “Due to my health condition, I now actively engage in walking through our residential complex, appreciating its natural environment. With abundant trees and diverse bird species, I particularly enjoy sitting to listen to their varied bird songs. The distinct calls of numerous unidentified birds fascinate me.” (Patient 16)
	Emphasizing relationship-building with family and friends	Quote 7: “Since I fell ill, my family has showered me with a lot of love . . . I think it is mutual. It’s hard to express in words, but it feels like an unspoken understanding: when you love your family, they love you back, especially during times like illness . . . They don’t let me do strenuous tasks, but instead encourage me to exercise and ensure I followed medical advice and take medication. All of this has been quite supportive.” (Patient 13)Quote 8: “If the individual maintains a carefree attitude, although their family may still worry because of psychological pressure, it will not be as significant.” (Patient 15)
Tangible lifestyle reformation	Changes in daily routine habits	Quote 9: “I used to have very irregular sleeping patterns, doing whatever I pleased . . . watching TV, using my phone into the late hours . . . After falling ill, I changed all of that. I make sure to go to bed before 11 p.m. and also take some rest at noon.” (Patient 6)
	Changes in dietary habits and structure	Quote 10: “Before I fell ill, I had a hearty appetite and often ate until I was full; however, after this illness, I realized that such eating habits might not be good for me. Now, I pay attention not to overeat, aiming to be about 80% full during meals.” (Patient 6)Quote 11: “Having a variety of foods with a mix of textures, balancing meat and vegetables, and paying attention to color coordination, like a rainbow meal, is important. Each color represents a different nutrient, so I try to incorporate a variety of colors in my meals—red, green, black, and so on. Essentially, when I cook, I focus on creating a well-balanced and colorful combination of foods.” (Patient 23)
	Changes in family relationships and work socialization methods	Quote 12: “I have reduced my social engagement compared to the past . . . especially those ineffective social activities like going out for drinks with friends. Activities that usually involve staying up late are less frequent for me.” (Patient 9)Quote 13: “Since I fell ill, I feel that my relationship with my daughter has become much more harmonious than before. In the past, we were both busy with our own lives and were from different generations with different perspectives. In terms of education or age, there were often clashes in our opinions. Things are generally much better now than before. She takes care of almost all the essential items in my life, insisting that I do not need to buy them . . . During my 1-month-plus hospitalization, she lost more than 10 kg. Every time she buys essential items for me, it feels good because I do not have to worry about it, and she is proactive and considerate. My siblings are also very caring, creating a positive atmosphere. I often tell everyone that I consider myself a “fool,” so I rarely feel like a patient. I do not dwell on those things.” (Patient 32)
	Establishment of exercise and health-preserving habits and cultivation of hobbies and interests	Quote 14: “During my illness, especially during chemotherapy, I mostly performed meditation. Reciting the Heart Sutra and practicing meditation, clearing my mind and not thinking about anything were very helpful for the recovery of my body.” (Patient 37)Quote 15: “Now, I do not push myself too hard in terms of exercise because I believe it is essential to listen to my body . . . I adjusted my daily 5-kilometer routine to every other day. I also incorporated a mix of cycling and running. Previously, I used to be run every day, but now, I combine running with cycling. It provides a stable and adaptable exercise approach, especially when the weather is favorable.” (Patient 19)
Increasing demand for medical advice and healthcare information	Demand for medical advice	Quote 16: “Typically, how long should Chinese medicine be soaked and boiled? Normally, I soak the herbs tonight and then cook them tomorrow night. I am wondering if this duration is too long.” (Patient 7)Quote 17: “Many people often experience discomfort and pain after chemotherapy, including abdominal pain and changes in bowel habits. Often, these are considered lingering effects, and specific reasons may not be identified during examinations. In such situations, I have two related questions. First, is it necessary to persistently seek medical advice and repeatedly visit physicians until a specific cause is identified? Second, regarding these discomforts, using methods like therapeutic spectrum devices or traditional Chinese therapies such as cupping and scraping, will there be any contraindications or precautions to consider when employing these approaches?” (Patient 26)Quote 18: “After undergoing radical rectal surgery with ostomy creation, I’ve experienced three unexpected episodes of excessive bowel discharge . . . These occurred without warning or apparent triggers—no dietary indiscretions, infections, or preceding symptoms. Though each episode resolved spontaneously without medication, the sudden profuse discharge caused extreme embarrassment. While no recurrence has happened in the past four in recent years, I remain hypervigilant, constantly worrying: ‘What if it strikes again?’ This lingering anxiety dominates my daily life.” (Patient 13)
	Need for healthcare	Quote 19: “I experience numbness in my hands and feet. Currently, my hands are not as affected, but my feet still feel numb despite daily soaking. However, I do not use any medicinal additives in foot soak. If I were to add medications, what kind of drugs would I need to include?” (Patient 23)Quote 20: “I have another question regarding what you mentioned earlier intestinal hypoxia during periods of high emotional stress and the use of breathing exercises as a method. I would like to learn how to practice this breathing exercise.” (Patient 7)
Benefit	Improvement in physical symptoms	Quote 21: “I feel that over this period, there has been a subtle shift in my mindset, especially toward a more positive outlook on the recovery phase of the treatment. When I feel low, I now know that Professor Pang can provide me with a mindful breathing exercise. I can listen to it and set aside other thoughts, whereas in the past, during times of emotional distress, I would isolate myself and brood.” (Patient 19)
	Improvement in psychological symptoms	Quote 22: “Previously, my sleep was consistently unstable and could be disrupted by eating too much at night or being more active. However, it has now reached a more balanced state.” (Patient 17)Quote 23: “Recently, my appetite has improved a little. After regulating my spleen and stomach, my food intake increased, and I gained two or three pounds in weight. My blood profile has also improved compared to before.” (Patient 24)
	Enhance self-health management capability	Quote 24: “Previously, it felt like I was in the dark . . . I was always curious about the post-treatment conditions, especially those who have been dealing with the illness for a longer time than me. Can I achieve similar results in the future . . . Other patients think this is when I should have diarrhea . . . This gives me confidence . . . The doctors are genuinely concerned about us . . . Some things like self-acupressure have been genuinely helpful . . . We’ve learned a lot.” (Patient 11)Quote 25: “In the past . . . I was not very clear about how I would spend the next 5 years. There was no well-defined plan, and I had to figure it out on my own. After going through these six training sessions, I feel that I have come to find meaningful things to do. For example, by establishing my values and then implementing them in concrete actions . . . I believe my goals are more defined now.” (Patient 19)

Theme 1: Foundational Outlook Transformation

Only through the patient’s interior driving force can genuine and sustainable change be achieved. Despite ongoing fluctuations in their condition, patients still were able to actively explore and adapt to their bodies during the TCM combined group psychotherapy intervention. They began progressively over the 6 weeks to seek positive emotions proactively, value life, keep tranquilized mind and empty thinking and emphasize relationship building with family and friends, and thereby rediscovered a new, balanced way of life.

Patients proactively sought positive emotions from week 3 session (Table 3, quote 1). They tried to avoid dwelling on unpleasant matters, reducing their anxiety about tumor recurrence and metastasis, and faced the disease, aging, and death more calmly. This optimistic attitude strengthened their love for life and future confidence.

After week 2 session, patients also placed a stronger emphasis on their physical health and gained a renewed appreciation for life (quotes 2, 3). They prioritized regular exercise, a balanced diet, consistent sleep, and healthy work routines. They also adhered to medical advice, attended regular checkups, and cultivated safety awareness—being vigilant against fraud, practicing road safety, and taking precautions when traveling. This heightened sense of life’s value accompanied their efforts to better manage health.

Since week 3 session, patients also learned to maintain inner tranquility and contentment, thereby weakening their pursuit of money and a career (quotes 4, 5, 6). By embracing nature, selectively enjoying gourmet food, and cultivating hobbies, they attained a state of tranquility and detachment. This mindset shift coincided with alleviated psychological stress and improved the participants’ quality of life.

Patients became aware of the importance of family and friends particularly after week 5’s discussions on social support (quotes 7, 8). They emphasized mutual assistance and transformed themselves into the focus of attention, embracing care and love from their loved ones. This attitude of valuing filial piety, independence, and mutual companionship with relatives helped the participants cope with the challenges brought by the illness.

Theme 2: Tangible Lifestyle Reformation

Through the intervention, patients learned many practical methods. From their feedback, they demonstrated a new rhythm of life via tangible lifestyle reformation. These efforts to regain control over their lives served to reduce their uncertainties and feelings of insecurity. The daily behavioral changes resulting from the TCM combined group psychotherapy intervention include 4 sub-themes: “change in daily routine habits,” “change in dietary habits and dietary structure,” “change in family relationships and work socialization methods,” and “establishment of exercise and health care habits and cultivation of interests and hobbies.”

Patients commonly altered their daily routines after week 2 symptom management training, adopting habits of going to bed and waking up early, maintaining regular schedules, and incorporating the practice of taking afternoon naps to enhance their sleep and overall quality of life (quote 9).

Patients also made significant changes to their dietary habits following week 2 nutritional guidance, including quitting drinking alcohol, starting to eat regular meals, controlling their portion sizes, and focusing on light, diverse, and high-protein diets. These changes improved their nutritional status and overall health (quotes 10, 11).

With the reduction in psychological burdens at work and home, patients experienced social adjustments most evident during week 5 family role discussions, and engaged in open communication with relatives and friends (quotes 12, 13). The patients also accepted more care and attention from their loved ones, leading to more harmonious family relationships.

Patients began to establish health-preserving habits consolidated since week 2 session, such as foot soaking and acupressure, and maintained various exercises, including running and swimming (quotes 14, 15). Simultaneously, they had cultivated interests and hobbies such as raising pets or hiking, all of which contributed to their physical and psychological well-being.

Theme 3: Increased Demand for Medical Advice and Healthcare Information

As the intervention progressed, patients became increasingly attentive to and valued their health, with queries intensifying mid-program (weeks 2-4) as they applied new skills. Throughout this process, patients began to identify numerous specific issues, leading to deeper, more concrete thoughts on disease self-management. These thoughts focused primarily on the need for medical advice and healthcare information.

Patients’ demands for medical advice included recommendations on medication selection, Chinese medicine decoction guidance, acupuncture advice, interpretation of physical symptoms and test results, suggestions for a follow-up examination, and chemotherapy regimen advice (quotes 16, 17, 18).

Patients’ needs for healthcare included recommendations for breathing techniques, medicinal foot baths, dietary advice, exercise recommendations, and self-acupressure guidance (quotes 19, 20).

Theme 4: Benefit

The change in mindset following illness led to improvements in both psychological and physical symptoms with distinct temporal patterns. By driving behavioral changes, the participants cultivated healthy lifestyle habits, further enhancing their physical well-being. In addition, meeting patients’ needs for healthcare and medical advice greatly boosted their self-management abilities regarding their health.

Patients’ anxiety and depression were effectively alleviated as early as week 2 (quote 21), aligning with rapid scale (SAS, SDS) improvements previously reported.²⁸ They learned how to adjust their mindset and positively faced the challenges brought by the illness.

The intervention not only improved patients’ psychological well-being but also provided some relief from their physical symptoms particularly after weeks 2-4 self-health management practices (quotes 22, 23). For instance, patients experienced enhanced sleep quality, increased appetite, and gradual physical recovery.

Following the full intervention, patients developed awareness of symptoms, treatment options, and recovery processes, and began actively planning for their future (quotes 24, 25). This aligned with delayed improvements in SAS, SDS, and QLQ-C30 cognitive function scores—underscoring that the cumulative self-health management capability cultivated throughout the 6-week program required complete exposure for mastery, rather than emerging mid-intervention.²⁸

Discussion

In this qualitative analysis of the clinical trial on TCM combined group psychotherapy, we explored CRC survivors’ lived experiences during the intervention. Participants reported transformed perspectives and behavioral shifts, concurrent with improved psychological and physical well-being.

Currently, numerous qualitative analyses have been conducted on CRC survivors’ experience and needs across various regions and populations. For example, several studies have focused on the immediate post-operative experiences,³² self-health management experiences during recovery,³³ and follow-up care and support needs of patients.³⁴ Similar to this study, these investigations have pointed out common physical symptoms experienced by patients after surgery, such as diarrhea, constipation, increased flatulence, and other bowel dysfunctions, as well as the resulting social embarrassment. Some studies have also indicated that patients seek support on their own when they feel unwell, including making dietary and behavioral adjustments, seeking support from family members and doctors, and maintaining a positive and optimistic mindset.^33,35

It can be observed that CRC survivors require comprehensive support during their recovery process, encompassing psychological, social, and informational aspects. Our intervention specifically provides a platform that, based on these needs, inspires and accelerates positive changes in patients.

Minor physical symptoms can easily trigger concerns about cancer recurrence.^36,37 Similar to balint groups,³⁸ health education,³⁹ and supportive group psychotherapy,⁴⁰ our platform offers relevant disease knowledge and guidance on self-health management and answers patients’ questions. Through our online intervention platform, patients learned a great deal about their illness, which allowed them to gain insights into common postoperative physical symptoms, such as frequent bowel movements, numbness in the hands and feet, and nausea. Furthermore, through patient communication and interaction, we were pleased to observe that patients spontaneously engaged in discussions to explore their shared physical symptoms and to exchange coping experiences, while also providing emotional support and encouragement to one another. These learning exchanges alleviated the participants’ feelings of loneliness and uncertainty, enabling them to perceive certain symptoms as typical post-operative occurrences, thereby mitigating negative emotions such as anxiety and fear related to cancer.

On the flip side, the platform aids CRC survivors in more openly accepting social support and confronting their illness. Influenced deeply by China’s family-oriented culture,^41,42 family members often have a significant impact on the attitudes of CRC survivors toward the disease. In this study, many patients’ family members showed “a lot of love” through careful caregiving and long hours of companionship, which was greatly appreciated by the patients. Some patients happily embraced this love and gained the courage to face their future lives. However, some patients exhibited signs of role diminishment, particularly those who were previously in charge of family affairs before falling ill. They may shift to rely on family support, both financially and for caregiving. In such cases, despite their illness, they remained worried about family matters and resisted, and even felt guilty about expressions of love from family members. Additionally, some patients reduced their social activities because of shame related to physical symptoms such as frequent gas or bowel movements.³² This was particularly pronounced among stoma patients, who described unique physiological challenges—unpredictable discharge, skin irritation—and psychological burdens like fear of public embarrassment triggering social withdrawal. With guidance from physicians, these patients began to identify their roles within their families and society, addressing stoma-specific concerns through peer exchange and clinical counseling, gradually accepting the love from family members, facing their illness more openly, and actively communicating their inner feelings with relatives and friends.

While the informational and social support play crucial roles in CRC survivors’ acceptance of support and confrontation of their illness, it’s worth noting that patients’ decisions are often shaped by broader cultural and religious factors as well. For instance, previous research has shown that TCM beliefs can significantly influence Chinese patients’ dietary decisions.⁴³ Although this presents a major obstacle to intervention for CRC survivors, it also provides an opportunity to improve self-health management abilities, as long as the advice is in line with cultural norms and expectations. Recognizing this, we integrated the concepts and methods of TCM into group psychotherapy, developing an intervention that aligns with the psychology and culture of Chinese people. In the second and third interventions, we successfully integrated TCM health knowledge, which was reflected in the proactive mindset and heightened interest from patients during supportive expression. This positive change extended to their behaviors, including adopting healthier dietary habits, managing their daily routines, and engaging in physical activity. In addition, we provided personalized guidance to patients on treatment methods, such as acupuncture, herbal bathing, and Dao-in. Patients exhibited high compliance and experienced benefits from actively practicing these methods, which alleviated physical symptoms such as insomnia, pain, and frequent bowel movements, further improving their negative emotions. At the same time, patients encountered specific issues in practice, such as decoction, cupping, and scraping contraindications. Through positive feedback in supportive expression, the participants received answers and further improved the effectiveness of TCM practice, thus creating a positive feedback loop.

Because of the aforementioned benefits, the patients’ interior driving force significantly increased. They voluntarily sought disease-related information, taking proactive practice and faced more specific challenges in their daily life, leading to a progressive enhancement in their self-health management capabilities.^33,44,45 Furthermore, the cognitive and behavioral changes in patients after the intervention were not temporary, but that this optimistic outlook on life, heightened awareness of health maintenance, and adaptive strategies for their bodies were deeply integrated into their future lives.

Limitations

Despite our efforts to ensure sample representativeness and generalizability by balancing factors such as age and gender, the study’s limitations must be acknowledged. Specifically, all participants were recruited from 2 tertiary hospitals affiliated with universities, both located in Beijing, the capital city of China. This geographic and institutional concentration may limit the sample’s representativeness, as variations in medical quality, humanistic care, and social cultures across regions can significantly impact the results. Additionally, when combined with the inherent challenges posed by the COVID-19 pandemic, particularly the inability of therapists to lead patients face-to-face due to social distancing measures, the study had to adopt an online format. This shift to virtual delivery, while necessary under the circumstances, introduced additional limitations that could potentially impact the effectiveness of the intervention. The lack of in-person interaction may hinder the establishment of rapport and trust between therapists and patients, as well as the development of strong group cohesion among participants. Regarding intervention adherence, most participants attended all live sessions. A minority (n < 5) missed 1-2 sessions due to personal commitments but reviewed recordings via the program applet. While this limited their engagement in real-time supportive expression, systematic thematic analysis of all transcripts post-intervention confirmed thematic saturation, indicating that partial attendance did not substantively alter core findings. Last, long-term follow-up mixed-method analysis is necessary to further elucidate the sustained effects of the intervention, including its impact on CRC survivors’ long-term lifestyle changes, physical and mental well-being, as well as to evaluate its efficacy and benefits on their risk of disease recurrence and survival outcomes.

Conclusion

CRC survivors require detailed and practical guidance during postoperative treatment and rehabilitation to help them regain a regular life rhythm after the dual trauma of physical and psychological challenges. The integration of TCM adapts to the personality traits and cultural customs of Chinese patients, which are often presented in a narrative format,^46,47 making it easier for patients to understand and accept practical advice and guidance in a relaxed manner. Many concepts and methods in TCM not only facilitated patients’ adoption of healthier lifestyles but were reflected in self-reported cognitive shifts. Through this process, patients reported gradually regaining their life rhythms and experiencing reduced uncertainties and feelings of insecurity. These outcomes further enhanced patient engagement and confidence, with participants describing increased proactive learning and practice of self-health management methods. Moreover, support from family and friends was perceived to strengthen confidence in overcoming the disease. Collectively, through detailed lifestyle coaching, positive peer-exchange platforms, and culturally sensitive delivery, patients transformed from passivity to proactivity—shifting from passive reception to active learning—with renewed internal motivation driving sustainable self-care practices during the intervention.

Footnotes

Acknowledgements

We sincerely thank all the patients and their caregivers who participated in our study by sharing their personal experiences and feelings. It was profoundly moving to see individuals open up about their wounds to support their peers. We gratefully acknowledge the support of Professor Yufei Yang from Xiyuan Hospital and Professor Lili Tang from Beijing Cancer Hospital. Additionally, we extend our gratitude to the physicians and research assistants at Xiyuan Hospital and Beijing Cancer Hospital for their invaluable assistance in recruiting and managing the patients.

ORCID iDs

Yipin Liu

Lingyun Sun

Zixu Wang

Ethical Considerations

The protocol has been approved by Ethic Committee of Xiyuan Hospital, China Academy of Chinese Medical Sciences (2022XLA079-1). All the procedures will follow in accordance with Declaration of Helsinki and International Ethical Guidelines for Biomedical Research Involving Human Subjects.

Consent to Participate

All patients will sign written informed consent before enrollment. No identifiable information about participants will be disclosed in this publication.

Authors Contributions

Lingyun Sun and Zixu Wang are joint corresponding authors. Yipin Liu and Zixu Wang wrote the first draft of the manuscript and conducted initial coding analysis. Lingyun Sun designed the study and revised and approved the final manuscript. Lingyun Sun and Jiaxi Liu recruited the participants and collected the data. Ying Pang and Zixu Wang will provide the psychotherapy intervention.

Funding

This study is funded by Scientific and Technological innovation Project of China Academy of Chinese Medical Science (C1202A01819) and the Foundation for Distinguished Young Scientists of China Academy of Chinese Medical Science (ZZ15-YQ-053).

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

All data of the clinical trial will be available under request to corresponding author Zixu Wang, (mariawzx@126.com) after the primary results being published.

Trial Registration Number

Chinese Clinical Trial Registry, ChiCTR2000041247.

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