---
title: "Symptom network analysis in gastric cancer: tools, core and bridge symptoms, and temporal patterns"
id: "plos-one-4-application-of-symptom-network-analysis-among-patients-with-gastric-cancer-a"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-4-application-of-symptom-network-analysis-among-patients-with-gastric-cancer-a"
content_type: "clinical_feed_article"
specialty: "Oncology"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358940"
published_at: "2026-09-21T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Symptom network analysis in gastric cancer: tools, core and bridge symptoms, and temporal patterns
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-4-application-of-symptom-network-analysis-among-patients-with-gastric-cancer-a
- **Specialty:** [Oncology](https://medichelpline.com/clinical-feed/oncology.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0358940)
- **Published At:** 2026-09-21T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This scoping review mapped evidence on the application of **symptom network analysis** in patients with **gastric cancer** by summarizing study characteristics, assessment tools, core and bridge symptoms, temporal symptom relationships, and associated factors. - The review followed Arksey and O’Malley and PRISMA-ScR guidance and searched nine databases through April 1, 2026, identifying 9 eligible studies (5 cross-sectional, 4 longitudinal). - Seven studies were conducted in China and two in South Korea; patient populations included perioperative, postoperative chemotherapy, and chemotherapy recipients. Two studies included mixed cancer samples containing gastric cancer patients (treated as indirect evidence). - Six symptom assessment instruments were used; the Chinese version of the **MDASI-GI-C** was the most frequent (reported in 7 studies). Other tools included MDASI, HADS, FACT-Ga, a 20-item Symptom Severity Scale, and a Traditional Chinese Medicine constitution classification. - Core symptoms identified across studies totaled nine; **fatigue** was the most frequently reported core symptom (identified in 5 studies), followed by pain, vomiting, sadness, altered taste, and loss of appetite among others. Core symptoms varied by treatment phase and symptom-burden subgroups. - Ten bridge symptoms were reported across three studies, including **loss of appetite**, sleep disturbances, somnolence, altered taste, dry mouth, abdominal distension, anxiety, and depression; bridge symptom identification varied considerably across studies. - Longitudinal cross-lagged analyses indicated time-ordered associations such as altered taste → loss of appetite and sadness → fatigue in specific chemotherapy cycles; other paths included vomiting → loss of appetite and abdominal distension → nausea at defined postoperative chemotherapy stages. - Recurrent strongly connected symptom pairs included **altered taste–loss of appetite** and **nausea–vomiting**, with many strong links among gastrointestinal, eating-related, and psychological symptoms. - All included studies used R for network estimation; methods and reporting varied: five used strength centrality to identify core symptoms, three reported stability and accuracy metrics, and methodological heterogeneity was noted in models, centrality/bridge indicators, and timing of assessments. - The review concludes that symptom profiles in gastric cancer are complex, dynamic, and heterogeneous. Recommendations from the authors include standardizing assessment tools and time points, conducting multicenter longitudinal studies, and developing interventions targeting core and bridge symptoms and key symptom pathways to enable individualized, stage-specific symptom management.
## Clinical Analysis & Structured Key Points
Application of symptom network analysis among patients with gastric cancer: A scoping review | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Peer Review Reader Comments Figures Figures Abstract Objective To map evidence on symptom network analysis in patients with gastric cancer by summarizing study characteristics, commonly used assessment tools, central and bridge symptoms, temporal symptom relationships, and associated factors, and to provide a basis for precision symptom management. Methods This scoping review was guided by the Arksey and O’Malley framework and reported in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR). PubMed, Web of Science, CINAHL, Cochrane Library, Embase, CNKI, Wanfang Data, VIP, and CBM were systematically searched from database inception to April 1, 2026. Original studies published in Chinese or English that applied symptom network analysis to gastric cancer populations, including eligible mixed cancer populations with gastric cancer patients, during the perioperative period or chemotherapy were included. Literature screening, data extraction, and narrative synthesis were performed. Results A total of 9 studies were included. Six symptom assessment tools were identified, with the Chinese version of the MD Anderson Symptom Inventory–Gastrointestinal Cancer Module (MDASI-GI-C) being the most frequently used tool (reported in 7 studies). Nine core symptoms were identified across the included studies, with fatigue being the most frequently reported core symptom (identified in 5 studies). Ten bridge symptoms were identified; however, considerable variation was observed in the identification of bridge symptoms across studies. Longitudinal analyses suggested that phlegm-dampness constitution was associated with subsequent changes in taste, while changes in taste were associated with subsequent appetite loss. Conclusions The symptom profiles of patients with gastric cancer are characterized by complexity, dynamic changes across treatment stages, and population heterogeneity. Symptom management strategies may benefit from individualized and stage-specific approaches targeting core symptoms, bridge symptoms, and key symptom pathways. Future research should focus on standardizing symptom assessment tools and assessment time points, conducting multicenter longitudinal studies, and supporting the development and evaluation of interventions for clinical practice. Trial registration OSF Registration DOI: https://doi.org/10.17605/OSF.IO/MJAZ3 Citation: Zhu Q, Duan Z, Dai Y, Chi J, Guan W, Dong L, et al. (2026) Application of symptom network analysis among patients with gastric cancer: A scoping review. PLoS One 21(9): e0358940. https://doi.org/10.1371/journal.pone.0358940 Editor: Jincheng Wang, Hokkaido University: Hokkaido Daigaku, JAPAN Received: May 5, 2026; Accepted: September 1, 2026; Published: September 21, 2026 Copyright: © 2026 Zhu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: No new datasets were generated in this study. All data analyzed in this scoping review were extracted from previously published studies, and all relevant data are included within the manuscript and its Supporting Information files. Funding: JC received funding from the General Program of the Yunnan Provincial Department of Science and Technology (Grant No. 202501AT070122; https://kjt.yn.gov.cn/ ), the Youth Project of the Chinese Nursing Association (Grant No. ZHKYQ202411; https://www.zhhlxh.org.cn/ ), and the Yunnan Health Training Project for High-Level Talents (Grant No. H-2025061). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors have declared that no competing interests exist. 1 Introduction Gastric cancer is one of the most common malignant tumors of the digestive system worldwide and remains a major global health burden. It ranks among the leading cancers in terms of both incidence and mortality, with approximately 968,000 new cases and 659,000 deaths reported annually worldwide. China contributes substantially to the global burden, accounting for approximately 37.02% of new cases and 39.44% of deaths [ 1 , 2 ]. Surgical treatment and chemotherapy remain the primary therapeutic approaches for gastric cancer. However, patients frequently experience multiple concurrent physical and psychological symptoms during the perioperative period and chemotherapy, with these symptoms often forming interconnected symptom clusters that complicate symptom management [ 3 , 4 ]. Symptom network analysis has emerged as a novel analytical approach for exploring complex symptom interactions. In a symptom network, symptoms are represented as nodes and their statistical associations as edges. Core symptoms are nodes with relatively high centrality and strong connectivity within the network [ 5 ], whereas bridge symptoms connect otherwise distinct symptom communities or domains [ 6 ]. By identifying central symptoms, bridge symptoms, and relationships among symptom nodes, this method provides new insights into symptom co-occurrence patterns and individualized symptom management strategies [ 7 ]. Although research on symptom networks in gastric cancer has gradually increased, variations remain in study populations, assessment instruments, and reported findings. Therefore, guided by Arksey and O’Malley’s scoping review framework [ 8 ], this study aims to summarize the application of symptom assessment tools, structural characteristics, and temporal changes in symptom networks among patients with gastric cancer, thereby providing insights for symptom management and future research in this field. 2 Materials and methods 2.1 Research questions This scoping review was guided by the following questions: (1) What symptom assessment tools have been used in symptom network studies among patients with gastric cancer? (2) Which core symptoms and bridge symptoms have been identified in gastric cancer symptom networks? (3) What key symptom associations and temporal relationships have been reported among symptoms? (4) What factors are associated with the identification of core symptoms in gastric cancer symptom networks? 2.2 Inclusion and exclusion criteria The inclusion criteria were developed according to the PCC framework (Participants, Concept, and Context) [ 9 ]. Studies were eligible if they met the following criteria: (1) Participants: patients diagnosed with gastric cancer, with no restrictions on age, sex, or ethnicity; (2) Concept: studies focusing on symptom network analysis in patients with gastric cancer, including the identification of core symptoms, bridge symptoms, symptom pathways, or network structures; and (3) Context: studies conducted during the perioperative period, chemotherapy period, or postoperative chemotherapy period. Given the limited evidence base, studies of mixed cancer populations were also eligible when gastric cancer patients were explicitly represented in the sample and the study examined symptom networks in a treatment context relevant to gastric cancer. Because gastric-cancer-specific networks could not be isolated in such studies, their findings were treated as indirect evidence and interpreted separately. Studies were excluded if they met any of the following criteria: (1) publications written in languages other than Chinese or English; (2) duplicate publications or studies for which the full text was unavailable; and (3) non-original research articles, including reviews, guidelines, case reports, conference abstracts, and conference proceedings. 2.3 Search strategy A comprehensive literature search was conducted in PubMed, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), the Cochrane Library, Embase, China National Knowledge Infrastructure, Wanfang Data, VIP Database, and CBM (Chinese Biomedical Literature Database). The search covered the period from database inception to April 1, 2026. A combination of controlled vocabulary/subject headings and free-text terms was used. Within each concept, synonymous terms were combined with the Boolean operator OR, and the gastric cancer concept was combined with the symptom network analysis concept using AND. Truncation was used where applicable, and the search syntax was adapted to the indexing rules and retrieval functions of each database. In addition, a snowballing approach was applied by manually screening the reference lists of the included studies and relevant articles to identify additional eligible records. The search terms were developed around two main concepts: gastric cancer and symptom network analysis. Chinese-language search terms corresponded to “gastric tumour”, “malignant gastric tumour”, “gastric cancer”, “symptom network”, “network analysis”, and “core symptoms”. English search terms included “gastric cancer*”, “stomach cancer*”, “gastric neoplasm*”, “stomach neoplasm*”, “malignant gastric neoplasm*”, “malignant stomach neoplasm*”, “cancer of the stomach”, “familial diffuse gastric cancer”, “symptom network*”, “network of symptoms”, “symptom network structure”, “network analysis”, “symptom network analysis”, “core symptom*”, and “key symptom*”. The complete PubMed strategy, including MeSH and title/abstract terms and Boolean combinations, is presented in Table 1 . Download: PNG larger image TIFF original image Table 1. PubMed search strategy. https://doi.org/10.1371/journal.pone.0358940.t001 2.4 Literature screening and data extraction Duplicate records were removed using Zotero 7.0. Two researchers, the first and second authors, independently screened all retrieved studies based on the predefined inclusion and exclusion criteria. In the first stage, titles and abstracts were reviewed to exclude clearly irrelevant studies. In the second stage, the full texts of potentially eligible studies were assessed. Disagreements were discussed with a third researcher, the corresponding author, until consensus was reached. The final included studies were then confirmed. Data were extracted using a standardized Microsoft Excel form. The extracted items included first author, publication year, country, study design, sample size, study population, assessment time points, assessment tools, and main findings. Methodological characteristics of the network analyses were also charted, including network model, software/packages, centrality indicators, bridge indicators, temporal indicators, and reporting of network stability and estimation accuracy. 2.5 Reporting guideline and methodological quality appraisal This review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), and the completed checklist is provided in S1 File . A formal risk-of-bias or methodological quality appraisal was intentionally not undertaken because the aim of this scoping review was to map the breadth, characteristics, methods, and findings of the available evidence rather than to estimate pooled intervention effects or grade certainty of evidence. Instead, methodological features directly relevant to the interpretation of symptom network studies, including network estimation approaches, centrality and bridge indicators, temporal indicators, and stability/accuracy reporting, were systematically charted. 2.6 Ethical review As this review was conducted solely on the basis of published studies, it did not involve human participants, individual-level data, or animal experiments. Ethical approval was therefore not required. The review protocol has been registered with the Open Science Framework under DOI: https://doi.org/10.17605/OSF.IO/MJAZ3 3 Results 3.1 Results of literature screening A total of 669 records were identified through the initial search. Following eligibility screening based on the predefined inclusion and exclusion criteria, 9 studies [ 10 – 18 ] were ultimately included in this review. The literature screening process is shown in S1 Fig . 3.2 Basic characteristics of the included studies Among the 9 included studies, 5 were cross-sectional studies [ 11 – 14 , 16 ] and 4 were longitudinal studies [ 10 , 15 , 17 , 18 ]. Seven studies were conducted in China [ 10 – 16 ], and two were conducted in South Korea [ 17 , 18 ]. The study populations mainly comprised patients receiving chemotherapy for gastric cancer, patients undergoing postoperative chemotherapy, and patients in the perioperative period of gastric cancer treatment. In addition, two studies [ 16 , 18 ] included mixed cancer populations with gastric cancer patients. These studies were retained to map potentially relevant evidence but were treated as indirect evidence because gastric-cancer-specific symptom networks were not reported. The detailed characteristics of the included studies are presented in Table 2 . Download: PNG larger image TIFF original image Table 2. Basic characteristics of the included studies (n = 9). https://doi.org/10.1371/journal.pone.0358940.t002 3.2.1 Symptom assessment tools. A total of six relevant assessment instruments were used across the included studies. The Chinese version of the MD Anderson Symptom Inventory–Gastrointestinal Cancer Module (MDASI-GI-C) was the most frequently used instrument (n = 7) [ 10 – 16 ]. The remaining instruments included the Classification and Determination of Traditional Chinese Medicine Constitution (n = 3) [ 10 , 11 , 13 ], the MD Anderson Symptom Inventory (MDASI) [ 17 ], the Hospital Anxiety and Depression Scale (HADS) [ 17 ], the Functional Assessment of Cancer Therapy–Gastric (FACT-Ga) [ 17 ], and the 20-item Symptom Severity Scale [ 18 ]. 3.2.2 Timing of symptom assessment. Perioperative studies assessed symptoms at multiple time points before and after surgery (n = 2) [ 12 , 17 ], including 1 week before surgery, 1 week after surgery, 7 days postoperatively, and 3–6 months after surgery. Chemotherapy-related studies primarily evaluated symptoms before and after chemotherapy or across different chemotherapy cycles (n = 5) [ 10 , 13 – 15 , 18 ], including assessments after the first, second, third, fourth, and sixth chemotherapy cycles, on the second day of chemotherapy, or from chemotherapy initiation to hospital discharge. In addition, two cross-sectional studies did not report detailed symptom assessment time points [ 11 , 16 ]. 3.3 Main findings A total of 7 studies [ 11 – 14 , 16 – 18 ] explicitly identified core symptoms across different treatment stages, while 3 studies [ 11 , 15 , 17 ] reported bridge symptoms. Three studies [ 11 – 13 ] explored factors associated with core symptoms, and 2 studies [ 10 , 15 ] examined temporal relationships among symptoms. The detailed characteristics are presented in Table 3 . All 9 studies [ 10 – 18 ] used R software for network estimation and visualization. Among them, 5 studies [ 11 , 12 , 14 , 17 , 18 ] used strength centrality to identify core symptoms, and 3 studies [ 12 , 15 , 16 ] reported the stability and accuracy of their network results. The detailed methodological characteristics are presented in Table 4 . Download: PNG larger image TIFF original image Table 3. Main findings of the included studies. https://doi.org/10.1371/journal.pone.0358940.t003 Download: PNG larger image TIFF original image Table 4. Network analysis methods and reporting characteristics. https://doi.org/10.1371/journal.pone.0358940.t004 3.3.1 Core symptoms. A total of 7 studies identified core symptoms among patients with gastric cancer or mixed cancer populations including patients with gastric cancer [ 11 – 14 , 16 – 18 ]. Regarding the frequency of identification, fatigue was reported as a core symptom in 5 studies, followed by pain and vomiting (3 studies each), and sadness, altered taste, and loss of appetite (2 studies each). Shortness of breath and certain quality-of-life-related symptoms were each reported in 1 study. Among these symptoms, fatigue was the most frequently identified core symptom and was repeatedly observed across different treatment phases, including among postoperative gastric cancer patients, patients receiving postoperative chemotherapy with high symptom burden, perioperative gastric cancer patients, and patients undergoing chemotherapy in mixed cancer populations [ 12 , 14 , 17 , 18 ]. The core symptoms varied across treatment phases. Among gastric cancer patients on postoperative day 7, vomiting, fatigue, and pain were identified as the primary core symptoms [ 12 ], whereas altered taste, vomiting, and loss of appetite were identified as core symptoms among patients receiving postoperative chemotherapy [ 13 ]. Furthermore, differences in core symptoms were observed among patient subgroups with different symptom burden levels [ 14 ]. 3.3.2 Bridge symptoms. Three studies identified bridge symptoms in symptom networks among patients with gastric cancer [ 11 , 15 , 17 ]. The identified bridge symptoms included sleep disturbances, loss of appetite, somnolence, altered taste, dry mouth, abdominal distension, anxiety, depression, emotional well-being, and physical health. Zou Yanling et al. [ 11 ] reported that sleep disturbances, loss of appetite, somnolence, and altered taste were identified as bridge symptoms among patients with gastric cancer undergoing chemotherapy. Li et al. [ 15 ] found that dry mouth served as a bridge symptom during the early stage of postoperative chemotherapy, whereas abdominal distension emerged as a bridge symptom during the middle and late stages of chemotherapy. Shim et al. [ 17 ] investigated symptom–quality of life associations and found that anxiety, depression, and emotional well-being played bridge roles before surgery, at 1 week postoperatively, and at 3–6 months postoperatively. Considerable variation was observed in the bridge symptoms identified across these three studies. 3.3.3 Temporal relationships among symptoms. Two studies further explored temporal relationships among symptoms in patients with gastric cancer [ 10 , 15 ]. Using cross-lagged network analysis, Li Siyu et al. [ 10 ] found that the path from sadness to fatigue showed a strong temporal association between the second and fourth chemotherapy cycles, whereas the path from altered taste to loss of appetite showed a strong association between the fourth and sixth cycles. Li et al. [ 15 ] reported that “vomiting → loss of appetite” showed the strongest positive cross-lagged association from the first to the third postoperative chemotherapy sessions, while “abdominal distension → nausea” showed the strongest cross-lagged association from the third to the sixth sessions; meanwhile, “altered taste → loss of appetite” showed the strongest cross-lagged association. Together, these studies suggest that the relationship between altered taste and loss of appetite may represent a relatively consistent temporal association across chemotherapy phases. Because both studies were observational, these cross-lagged paths should be interpreted as time-ordered statistical associations rather than evidence of causal effects. 3.3.4 Strongly connected symptom pairs. Several studies reported symptom pairs with strong associations within gastric cancer symptom networks, primarily involving gastrointestinal symptoms, eating-related symptoms, and psychological and emotional symptoms [ 11 , 13 – 18 ]. Among these, “altered taste–loss of appetite” and “nausea–vomiting” were repeatedly identified as strongly connected symptom pairs across multiple studies, reflecting important symptom interactions related to gastric cance
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