Current status of anxiety following total hysterectomy in endometrial cancer patients: A cross-sectional study
Endometrial cancer is one of the most common malignant tumors of the female reproductive system, with its incidence rising significantly over the past few decades due to global population aging and lifestyle changes.  According to the World Health Organization (WHO), endometrial cancer is the fourth most common cancer among women worldwide, with both incidence and mortality rates increasing in China in recent years.  While endometrial cancer primarily affects postmenopausal women, its prevalence in younger women is also rising due to shifts in lifestyle and environmental factors.  The main risk factors for endometrial cancer include excess estrogen, obesity, hypertension, and polycystic ovary syndrome.  In clinical practice, surgical resection, particularly total hysterectomy, remains the primary treatment for endometrial cancer.  This approach is effective in controlling local tumor spread and significantly improves patient survival rates.  With advancements in minimally invasive techniques, laparoscopic surgery is increasingly replacing traditional open procedures due to its benefits of reduced trauma, quicker recovery, and fewer complications.  Despite these improvements in surgical techniques, postoperative patients continue to face significant psychological challenges, with anxiety being highly prevalent.  Anxiety, a common psychological response to stress, is prevalent among patients with chronic diseases, particularly cancer patients.  Postoperative anxiety not only impacts patients’ quality of life but can also delay recovery and negatively influence treatment outcomes.  Research has shown that anxiety levels in cancer patients are influenced by several factors, including social support, economic status, education level, disease severity, and type of surgery.  In endometrial cancer patients specifically, the incidence of postoperative anxiety varies across studies, but it is consistently recognized as being high and requiring prompt attention from healthcare providers.  Existing literature indicates that socio-demographic factors such as age, marital status, occupation, education level, and economic status significantly impact anxiety levels in patients.  For instance, younger patients may experience greater psychological stress due to concerns related to childbearing and family responsibilities, whereas higher education levels and strong social support can help mitigate anxiety.  Clinical characteristics, including tumor size, stage, presence of metastases, and surgical approach, also influence patients’ psychological well-being. In particular, patients with larger tumors or advanced-stage disease often face a higher risk of anxiety due to poorer prognosis and more complex treatment requirements.  In China, despite the rising incidence of endometrial cancer, relatively few studies have explored the prevalence of postoperative anxiety and its influencing factors. Differences in social support structures, family dynamics, and healthcare resource distribution between Chinese patients and those in Western countries may result in distinct patterns and contributing factors for anxiety.  Thus, gaining an in-depth understanding of anxiety and its determinants in postoperative endometrial cancer patients is crucial for developing targeted psychological interventions and enhancing patients’ quality of life. The role of psychological intervention in cancer treatment is increasingly acknowledged.  Appropriate psychological support can effectively reduce anxiety, encourage positive coping strategies, and enhance quality of life. Understanding the prevalence and contributing factors of postoperative anxiety is crucial for developing targeted interventions.  By identifying high-risk groups, healthcare professionals can provide tailored psychological support and optimize care plans, ultimately improving the overall treatment experience and prognosis of patients.  This study aims to evaluate the prevalence of postoperative anxiety and analyze its socio-demographic and clinical determinants through a cross-sectional survey of 74 endometrial cancer patients who underwent total hysterectomy. The findings will serve as a valuable reference for clinical staff to better identify and manage high-risk patients during postoperative care, ultimately enhancing the overall treatment experience and prognosis. 

2.1. Study design This study was approved by the Ethics Committee of The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture. This study employed a cross-sectional design to assess the prevalence of anxiety and its influencing factors in endometrial cancer patients following total hysterectomy. The study protocol received approval from the hospital’s Ethics Committee, and all participants provided informed consent, ensuring their understanding of the study’s purpose, procedures, and potential risks, as well as guaranteeing their right to voluntary participation. Participant privacy was strictly protected, with data used exclusively for research purposes and not disclosed publicly or used for other purposes. The study was conducted in the Department of Obstetrics and Gynecology of our hospital, ensuring a diverse sample and representative results. Data collection took place from January 2019 and January 2024, covering a complete clinical cycle and reflecting the immediate psychological status of postoperative patients. 2.2. Study subjects Inclusion criteria: Age: female patients aged 18 years and older. Diagnosis: diagnosed with endometrial cancer and have undergone total hysterectomy. Cognitive ability: able to read, comprehend, and independently complete questionnaires. Consent: voluntary participation with signed informed consent to ensure ethical compliance. Exclusion criteria: History of mental illness: patients with a history of mental illness or undergoing psychiatric treatment, to avoid interference in anxiety assessment. Serious physical illness: patients with comorbidities of other serious physical conditions (e.g., advanced heart disease, hepatic or renal failure) that could impact questionnaire administration and result accuracy. Cognitive dysfunction: patients with cognitive impairments (e.g., dementia, severe memory loss) unable to understand the questionnaire content. Recent major life events: patients who have recently experienced significant life events (e.g., death of a loved one, divorce) to minimize the impact of external factors on anxiety levels and ensure the internal validity of the study results. 2.3. Data collection Data collection involved a combination of face-to-face interviews and self-administered questionnaires. For patients unable to complete the questionnaire independently, face-to-face interviews were conducted as an alternative. Self-administered questionnaires improved the efficiency and convenience of data collection. A specially trained research assistant or nurse ensured standardization and consistency throughout the data collection process, minimizing potential human error. Survey content included: Socio-demographic characteristics (see Table ), such as age, marital status, education, occupation, income level, and place of residence (urban/rural). Disease-related factors (see Table ), including International Federation of Gynaecology and Obstetrics (FIGO) stage of endometrial cancer, surgical method (laparoscopic or open surgery), postoperative treatment (e.g., chemotherapy, radiotherapy, and observation), treatment regimen and number of cycles, time of diagnosis, and comorbidities (e.g., hypertension, diabetes). Psychometric tools (see Table ), specifically the Self-Assessment Scale for Anxiety (SAS). The SAS is a widely used instrument with strong reliability and validity, suitable for assessing patients’ anxiety levels. 2.4. Variables The dependent variable (outcome) was the level of anxiety, categorized as no anxiety, mild anxiety, moderate anxiety, or severe anxiety based on SAS scores (see Table ). Independent variables included sociodemographic factors (see Table ), disease-related factors (see Table ), and psychosocial factors (see Table ). 2.5. Statistical analyses All data analyses were conducted using SPSS 25.0 software. Continuous variables were expressed as mean ± standard deviation (mean ± SD) if normally distributed, or as median (quartiles) if not normally distributed. Categorical variables were presented as frequencies and percentages (n, %) to describe the sample characteristics (see Tables – ). Differences among groups with varying anxiety levels were compared using 1-way analysis of variance (ANOVA). For continuous variables, t tests or ANOVA were applied for comparison, while categorical variables were analyzed using the chi-square test to assess associations with anxiety levels (see Tables and ). Multifactorial analysis was performed using logistic regression to identify independent factors affecting anxiety, with anxiety as the dependent variable and including significant independent variables from univariate analyses (see Table ). A significance level of P < .05 was set, and all statistical tests were 2-sided. 

This study was approved by the Ethics Committee of The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture. This study employed a cross-sectional design to assess the prevalence of anxiety and its influencing factors in endometrial cancer patients following total hysterectomy. The study protocol received approval from the hospital’s Ethics Committee, and all participants provided informed consent, ensuring their understanding of the study’s purpose, procedures, and potential risks, as well as guaranteeing their right to voluntary participation. Participant privacy was strictly protected, with data used exclusively for research purposes and not disclosed publicly or used for other purposes. The study was conducted in the Department of Obstetrics and Gynecology of our hospital, ensuring a diverse sample and representative results. Data collection took place from January 2019 and January 2024, covering a complete clinical cycle and reflecting the immediate psychological status of postoperative patients. 

Inclusion criteria: Age: female patients aged 18 years and older. Diagnosis: diagnosed with endometrial cancer and have undergone total hysterectomy. Cognitive ability: able to read, comprehend, and independently complete questionnaires. Consent: voluntary participation with signed informed consent to ensure ethical compliance. Exclusion criteria: History of mental illness: patients with a history of mental illness or undergoing psychiatric treatment, to avoid interference in anxiety assessment. Serious physical illness: patients with comorbidities of other serious physical conditions (e.g., advanced heart disease, hepatic or renal failure) that could impact questionnaire administration and result accuracy. Cognitive dysfunction: patients with cognitive impairments (e.g., dementia, severe memory loss) unable to understand the questionnaire content. Recent major life events: patients who have recently experienced significant life events (e.g., death of a loved one, divorce) to minimize the impact of external factors on anxiety levels and ensure the internal validity of the study results. 

Data collection involved a combination of face-to-face interviews and self-administered questionnaires. For patients unable to complete the questionnaire independently, face-to-face interviews were conducted as an alternative. Self-administered questionnaires improved the efficiency and convenience of data collection. A specially trained research assistant or nurse ensured standardization and consistency throughout the data collection process, minimizing potential human error. Survey content included: Socio-demographic characteristics (see Table ), such as age, marital status, education, occupation, income level, and place of residence (urban/rural). Disease-related factors (see Table ), including International Federation of Gynaecology and Obstetrics (FIGO) stage of endometrial cancer, surgical method (laparoscopic or open surgery), postoperative treatment (e.g., chemotherapy, radiotherapy, and observation), treatment regimen and number of cycles, time of diagnosis, and comorbidities (e.g., hypertension, diabetes). Psychometric tools (see Table ), specifically the Self-Assessment Scale for Anxiety (SAS). The SAS is a widely used instrument with strong reliability and validity, suitable for assessing patients’ anxiety levels. 

The dependent variable (outcome) was the level of anxiety, categorized as no anxiety, mild anxiety, moderate anxiety, or severe anxiety based on SAS scores (see Table ). Independent variables included sociodemographic factors (see Table ), disease-related factors (see Table ), and psychosocial factors (see Table ). 

All data analyses were conducted using SPSS 25.0 software. Continuous variables were expressed as mean ± standard deviation (mean ± SD) if normally distributed, or as median (quartiles) if not normally distributed. Categorical variables were presented as frequencies and percentages (n, %) to describe the sample characteristics (see Tables – ). Differences among groups with varying anxiety levels were compared using 1-way analysis of variance (ANOVA). For continuous variables, t tests or ANOVA were applied for comparison, while categorical variables were analyzed using the chi-square test to assess associations with anxiety levels (see Tables and ). Multifactorial analysis was performed using logistic regression to identify independent factors affecting anxiety, with anxiety as the dependent variable and including significant independent variables from univariate analyses (see Table ). A significance level of P < .05 was set, and all statistical tests were 2-sided. 

3.1. Sociodemographic and clinical characteristics of the study subjects A total of 74 endometrial cancer patients who underwent total hysterectomy were included in this study. The majority of patients were aged 56 years or older (66.22%), with 85.14% being married, and 43.24% working as farmers or migrant workers. Educational levels were predominantly middle school (36.49%) and high school (32.43%), with 54.05% residing in rural areas. Most patients had a monthly family income between RMB 6000 and 12,000 (59.46%), and medical insurance was primarily covered by the new rural cooperative medical care system (55.41%). Low social support was reported by 33.78% of participants (see Table for details). In terms of disease characteristics, laparoscopic surgery was performed in most cases (87.84%), with total hysterectomy in 64.86%, and 52.70% receiving adjuvant therapy postsurgery. Tumor size was <4 cm in 77.03% of patients, 75.68% were in stage I, 91.89% had adenocarcinoma, and 36.49% had a history of chronic disease (see Table for details). 3.2. SAS assessment of the study subjects The mean SAS score for the 74 endometrial cancer patients who underwent total hysterectomy was 43.62 ± 8.27. Based on the SAS evaluation criteria, 33.78% of patients experienced anxiety, with 18.92% (14/74) having mild anxiety, 12.16% (9/74) moderate anxiety, and 2.70% (2/74) severe anxiety. See Table and Figure for details. 3.3. Anxiety distribution by sociodemographic characteristics of the study subjects Anxiety distribution across different socio-demographic characteristics showed that education level, lifestyle, and social support were significantly associated with anxiety (Table ). Specifically, anxiety was most prevalent among those with lower secondary education (55.56%), while the lowest anxiety prevalence was observed in patients with tertiary education (25.00%), indicating that lower education levels may increase the risk of anxiety. Regarding lifestyle, patients with unstable living situations had significantly higher anxiety rates compared to those living with family members (63.64% vs 28.57%), suggesting that an unstable lifestyle may elevate anxiety risk. Additionally, anxiety prevalence was significantly higher among those with low social support (56.00%) compared to those with high social support (21.43%), indicating inadequate social support as a key factor in anxiety. Other variables, such as age, marital status, occupation, place of residence, family income, and health insurance status, were not significantly associated with anxiety. 3.4. Anxiety distribution by disease characteristics of the study subjects Anxiety distribution among patients with different disease characteristics showed that tumor size and FIGO stage were significantly associated with anxiety (Table ). Anxiety prevalence was significantly higher in patients with tumors ≥4 cm (58.82%) compared to those with tumors <4 cm (26.32%), suggesting that larger tumors may increase the risk of anxiety. Similarly, anxiety was significantly more common in patients with FIGO stage III + IV (72.73%) compared to those with stage I (28.57%), indicating that advanced disease stage is a key factor in anxiety. Other variables, such as surgical approach, extent of hysterectomy, postoperative treatment, histological type, presence of metastasis, and history of chronic disease, were not significantly associated with anxiety. 3.5. Analysis of factors influencing anxiety in the study subjects Multifactorial logistic regression analysis indicated that education level, living arrangement, social support, tumor size, and FIGO stage were independent factors influencing postoperative anxiety (see Table for assigned values). Specifically, patients with junior high school education had a higher risk of anxiety compared to those with primary education or below (OR = 1.866, P = .014). Those with unstable living arrangements had greater anxiety risk compared to those living with family (OR = 2.285, P = .016). Low social support was associated with increased anxiety risk compared to high social support (OR = 2.806, P = .044). Patients with tumors ≥4 cm had a higher risk of anxiety compared to those with tumors <4 cm (OR = 3.328, P = .021). Additionally, patients with FIGO stage III + IV had a higher risk of anxiety compared to those with stage I (OR = 3.762, P = .01). See Table for further details. 

A total of 74 endometrial cancer patients who underwent total hysterectomy were included in this study. The majority of patients were aged 56 years or older (66.22%), with 85.14% being married, and 43.24% working as farmers or migrant workers. Educational levels were predominantly middle school (36.49%) and high school (32.43%), with 54.05% residing in rural areas. Most patients had a monthly family income between RMB 6000 and 12,000 (59.46%), and medical insurance was primarily covered by the new rural cooperative medical care system (55.41%). Low social support was reported by 33.78% of participants (see Table for details). In terms of disease characteristics, laparoscopic surgery was performed in most cases (87.84%), with total hysterectomy in 64.86%, and 52.70% receiving adjuvant therapy postsurgery. Tumor size was <4 cm in 77.03% of patients, 75.68% were in stage I, 91.89% had adenocarcinoma, and 36.49% had a history of chronic disease (see Table for details). 

The mean SAS score for the 74 endometrial cancer patients who underwent total hysterectomy was 43.62 ± 8.27. Based on the SAS evaluation criteria, 33.78% of patients experienced anxiety, with 18.92% (14/74) having mild anxiety, 12.16% (9/74) moderate anxiety, and 2.70% (2/74) severe anxiety. See Table and Figure for details. 

Anxiety distribution across different socio-demographic characteristics showed that education level, lifestyle, and social support were significantly associated with anxiety (Table ). Specifically, anxiety was most prevalent among those with lower secondary education (55.56%), while the lowest anxiety prevalence was observed in patients with tertiary education (25.00%), indicating that lower education levels may increase the risk of anxiety. Regarding lifestyle, patients with unstable living situations had significantly higher anxiety rates compared to those living with family members (63.64% vs 28.57%), suggesting that an unstable lifestyle may elevate anxiety risk. Additionally, anxiety prevalence was significantly higher among those with low social support (56.00%) compared to those with high social support (21.43%), indicating inadequate social support as a key factor in anxiety. Other variables, such as age, marital status, occupation, place of residence, family income, and health insurance status, were not significantly associated with anxiety. 

Anxiety distribution among patients with different disease characteristics showed that tumor size and FIGO stage were significantly associated with anxiety (Table ). Anxiety prevalence was significantly higher in patients with tumors ≥4 cm (58.82%) compared to those with tumors <4 cm (26.32%), suggesting that larger tumors may increase the risk of anxiety. Similarly, anxiety was significantly more common in patients with FIGO stage III + IV (72.73%) compared to those with stage I (28.57%), indicating that advanced disease stage is a key factor in anxiety. Other variables, such as surgical approach, extent of hysterectomy, postoperative treatment, histological type, presence of metastasis, and history of chronic disease, were not significantly associated with anxiety. 

Multifactorial logistic regression analysis indicated that education level, living arrangement, social support, tumor size, and FIGO stage were independent factors influencing postoperative anxiety (see Table for assigned values). Specifically, patients with junior high school education had a higher risk of anxiety compared to those with primary education or below (OR = 1.866, P = .014). Those with unstable living arrangements had greater anxiety risk compared to those living with family (OR = 2.285, P = .016). Low social support was associated with increased anxiety risk compared to high social support (OR = 2.806, P = .044). Patients with tumors ≥4 cm had a higher risk of anxiety compared to those with tumors <4 cm (OR = 3.328, P = .021). Additionally, patients with FIGO stage III + IV had a higher risk of anxiety compared to those with stage I (OR = 3.762, P = .01). See Table for further details. 

A cross-sectional survey of 74 endometrial cancer patients who underwent total hysterectomy found that 33.78% experienced anxiety, with 18.92% having mild anxiety, 12.16% moderate, and 2.70% severe. Univariate and multivariate logistic regression analyses identified education level, living arrangements, social support, tumor size, and FIGO stage as independent factors influencing postoperative anxiety. Approximately one-third of postoperative endometrial cancer patients in this study experienced anxiety, consistent with findings from previous research.  For instance, Wang et al  reported that postoperative anxiety in cancer patients ranged from 25% to 35%. The high prevalence of anxiety underscores the need for urgent attention and intervention for postoperative mental health issues.  The effect of education level on anxiety was significant in this study. Patients with lower secondary education had a significantly higher risk of anxiety compared to those with tertiary education (OR = 1.866, P = .014). This finding aligns with existing literature, which suggests that low education levels are associated with reduced health literacy and coping strategies, potentially leading to greater uncertainty and fear when facing illness.  Additionally, patients with unstable living arrangements had a significantly higher risk of anxiety compared to those living with family members (OR = 2.285, P = .016). This may be because a stable home environment offers more emotional support and security, thereby reducing anxiety.  Previous studies have demonstrated a strong link between home environment stability and mental health.  Inadequate social support was also a significant factor contributing to postoperative anxiety in this study (OR = 2.806, P = .044). Social support helps patients cope with the stress and challenges of illness by providing emotional, informational, and practical assistance.  Lack of sufficient social support may increase anxiety by making patients feel isolated and helpless during recovery. Related studies have indicated that patients with higher levels of social support exhibit better psychological resilience when facing illness.  Tumor size and FIGO stage significantly impacted patients’ anxiety levels (OR = 3.328, P = .021; OR = 3.762, P = .01). Larger tumors and advanced stages often indicate a more complex treatment course and poorer prognosis, which can heighten concerns about disease recurrence and survival, thereby increasing anxiety.  Similar studies have demonstrated a positive correlation between disease severity and psychological stress in patients.  The findings of this study suggest that clinical attention should focus on endometrial cancer patients with low education levels, unstable living arrangements, insufficient social support, large tumors, and advanced stages to provide targeted psychological interventions. For instance, health education can be enhanced for patients with lower education levels to improve their understanding of the disease and treatment, thereby reducing anxiety caused by lack of information.  For patients with unstable living arrangements and insufficient social support, coping skills and psychological resilience can be strengthened through support groups or psychological counseling services.  Additionally, comprehensive psychological assessments and interventions should be provided for patients with larger tumors and advanced stages to help alleviate disease-related stress. This study has several limitations. Firstly, the cross-sectional design does not establish causal relationships between variables but only reveals correlations.  Secondly, the study had a small sample size, including only 74 patients, which may affect the extrapolation and statistical power of the results. Nevertheless, we believe that this study provides valuable preliminary data for understanding the prevalence and influencing factors of anxiety after surgery for endometrial cancer. However, future studies should consider expanding the sample size to improve the representativeness and statistical power of the findings and ensure their wide applicability and credibility.  Finally, the study did not account for certain potential confounding factors, such as patients’ prior mental health status, specifics of family support systems, and personality traits, which may influence postoperative anxiety and affect the internal validity of the results. In addition, the assessment criteria of social support used in this study are relatively simple, and no specific quantitative measurement tools are used, which may limit the accurate assessment of the impact of social support on postoperative anxiety. Future studies should adopt more systematic and quantitative social support assessment methods, such as social support scales, to provide more accurate measurements. The potential effects of other clinical features, such as pathological types and risk of postoperative recurrence, on anxiety levels were not explored in depth. Studies have shown that the type of pathology and the risk of postoperative recurrence may be closely related to the psychological state of patients, so future studies should consider the impact of these factors on anxiety to obtain more comprehensive conclusions. In conclusion, this study highlights the prevalence of anxiety in postoperative endometrial cancer patients and identifies key influencing factors, including education level, living arrangements, social support, tumor size, and FIGO stage. Clinical focus on these high-risk factors is crucial to improving patients’ mental health and enhancing their quality of life through targeted psychological interventions and support. 

Conceptualization: Jing Yang, Huan Liang, Hongcheng Zhu. Data curation: Jing Yang, Huan Liang, Hongcheng Zhu, Xiaoling Liu. Formal analysis: Jing Yang, Huan Liang, Xiaoling Liu, Ting Yang. Investigation: Jing Yang, Hongmei Xiang. Methodology: Jing Yang, Huan Liang, Hongmei Xiang. Supervision: Ting Yang. Validation: Huan Liang, Xiaoling Liu, Hua Xiao. Visualization: Huan Liang, Hongcheng Zhu, Hongmei Xiang, Hua Xiao, Ting Yang. Writing – original draft: Jing Yang, Huan Liang, Hongcheng Zhu, Hongmei Xiang, Hua Xiao, Ting Yang. Writing – review & editing: Jing Yang, Huan Liang. 

