Integrated narrative and cognitive therapy enhances psychological and functional recovery after ultra-low sphincter-preserving surgery for low rectal cancer: A randomized controlled trial with exploratory oncologic outcomes.

BACKGROUND

Ultra-low sphincter-preserving surgery (ULSPS) for low rectal cancer often results in persistent bowel and sexual dysfunction alongside significant psychological distress, which may adversely affect recovery and may be associated with longer-term oncologic outcomes. Evidence on integrated psychosocial interventions in this context remains limited.

OBJECTIVE

To evaluate whether a structured six-month psychosocial intervention integrating narrative therapy and cognitive behavioral therapy improves psychological and functional recovery after ultra-low sphincter-preserving surgery for low rectal cancer, and to explore its associations with inflammatory markers, postoperative recovery metrics, and exploratory oncologic outcomes.

METHODS

In this single-centre, randomized controlled trial, 172 patients with AJCC stage I-III low rectal cancer undergoing ULSPS were assigned (1:1) to standard ERAS-based care or an integrated six-month psychosocial program combining narrative therapy and Beck cognitive behavioral therapy (CBT). Primary outcomes included depression (BDI-II), anxiety (BAI), bowel function (LARS), and sexual function (IIEF-5, FSFI). Secondary endpoints comprised inflammatory markers, recovery metrics, and exploratory oncologic outcomes, including disease-free survival (DFS) and overall survival (OS). Analyses were performed using linear mixed-effects models, Kaplan-Meier methods, and Cox regression with prespecified covariates.

RESULTS

The intervention group demonstrated significantly greater reductions in depression and anxiety, with between-group differences exceeding prespecified clinically meaningful change thresholds. Improvements in bowel and sexual function were clinically and statistically significant, accompanied by lower postoperative CRP, IL-6, and TNF-α. Recovery metrics favored the intervention (shorter hospital stay, earlier bowel recovery). In exploratory survival analyses, 2-year disease-free survival was 89.5% versus 74.4% (HR 0.48, 95% CI 0.24-0.96), and overall survival was 92.4% versus 79.1% (HR 0.42, 95% CI 0.19-0.93). These oncologic findings should be interpreted cautiously because DFS and OS were secondary exploratory outcomes, the number of events was modest, follow-up was relatively short, and the study was conducted at a single centre.

CONCLUSIONS

An integrated narrative-CBT intervention was associated with clinically meaningful improvements in emotional and functional recovery after ULSPS for low rectal cancer. Favorable DFS and OS estimates were observed as exploratory secondary findings but should be considered hypothesis-generating rather than definitive evidence of oncologic benefit. These findings support further evaluation of structured psychosocial programs as adjuncts to ERAS-based perioperative care pathways.