Re-authoring the altered self: the impact of a three-phase narrative nursing intervention on body image and distress in oral squamous cell carcinoma

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Background Locally advanced oral squamous cell carcinoma (OSCC) and its surgical treatment precipitate profound body image disturbance and psychological distress. With the increasing adoption of neoadjuvant immunochemotherapy (NICT), patients now experience fundamentally different treatment trajectories, yet the psychological implications of this paradigm shift remain poorly understood. Methods This prospective, comparative mixed-methods cohort study investigated longitudinal trajectories of body image disturbance (Body Image Scale, BIS) and psychological distress (Hospital Anxiety and Depression Scale, HADS) in OSCC patients undergoing either NICT followed by surgery ( n = 77) or upfront surgery (US; n = 77) following propensity score matching. Assessments occurred at baseline, post-neoadjuvant therapy (for the NICT group) or immediately pre-surgery (for the US group), at discharge, and 3 months post-surgery. Linear mixed-effects models analyzed time-by-group interactions. A qualitative phenomenological phase ( n = 15) explored subjective experiences. Results Significant time-by-group interactions were observed for both BIS [ F (3,456) = 18.5, p < 0.001] and HADS-Total ( F (3,456) = 14.2, p < 0.001). The NICT group exhibited elevated distress pre-surgery (T1: HADS-Total 15.8 vs. 12.9, p = 0.004) but demonstrated superior recovery by three months (T3: BIS 11.5 vs. 14.2, p = 0.002; HADS-Total 12.2 vs. 15.5, p < 0.001). Qualitative analysis revealed divergent psychological experiences: NICT patients endured prolonged anticipatory grief (“saying goodbye slowly”), while US patients experienced traumatic shock (“waking up to a stranger”). Conclusion NICT and US pathways generate fundamentally different psychological trajectories. Despite heightened pre-surgical distress, NICT patients demonstrate more robust psychological recovery, potentially facilitated by gradual adaptation. These findings support pathway-specific psychosocial interventions.

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