Gynecological cancers—including malignancies of the cervix, ovaries, uterus, vagina, and vulva—represent a significant health challenge for women and gender-diverse people assigned or presumed female worldwide [1-3]. Prevalence and age incidence vary across settings—cervical cancer disproportionately affects those in low- and middle-income countries largely due to higher human papillomavirus prevalence and limited screening [4,5], whereas endometrial cancer is increasing in high-income regions, linked to obesity and aging populations [6,7]. Even as advances in diagnosis and treatment have improved survival rates, those affected can experience psychological distress, including anxiety, depression, fear of recurrence, anger, shame, low self-esteem, and reduced quality of life (QoL) [3,8], often compounded by disruption to reproductive and sexual health [9,10]. Gynecological cancers also carry gendered stigma, with transgender people experiencing a particular sense of disconnect when they are diagnosed with a cancer that does not align with their gender identity [11,12]. As a result, they often report feeling uncomfortable attending support groups organized according to sex assigned at birth [13,14].

However, despite its recognition as an essential component of cancer care, psychosocial care remains inconsistently embedded worldwide [15,16]. Across both high- and low-income countries, survivorship support is often fragmented, reactive, and primarily biomedical, focusing on disease surveillance rather than long-term emotional and social recovery [17,18]. Existing psychosocial interventions—including counseling, cognitive behavioral therapy, and mindfulness-based approaches—have shown efficacy in reducing anxiety and depression in survivors of cancer [19,20]. However, the evidence base remains heterogeneous, with substantial variation in intervention content, delivery format, and outcome measurement, making it difficult to determine what works best, for whom, and under which circumstances [21]. Structural barriers including workforce shortages, long wait times, and stigma around mental health can further exacerbate inequalities and restrict access [22-24]. Additionally, clinical guidelines [25] offer limited direction on how best to embed psychosocial care across the patient pathway. This creates the need for accessible, scalable, and adjunctive approaches deliverable outside specialist services, particularly for those who fall below the threshold for formal psychological support.

One promising strategy is using creative arts and literature–based digital health interventions (hereafter referred to as “arts and health”) as a form of community psychosocial support [26,27]. Their online format can improve accessibility for people living in remote or underserved areas and lessen the stigma associated with formal psychological therapy [28,29]. Additionally, arts and health interventions remain relatively low cost, resource efficient, and scalable to diverse populations [30,31]. Within this field, shared reading (SR) is an established model of facilitated literary engagement. It involves trained reader leaders who select short stories, novel extracts, or poems to read aloud. During the reading, planned reflective pauses are used to invite participants’ thoughts, feelings, and associations around classic literature [26,32-34]. This deliberate use of meaningful pauses is a defining feature of SR intended to foster deep engagement with the material read and support immediate, in-the-moment reflections [35]. Studies of SR across diverse populations, including prisons, dementia care, substance use recovery, and chronic pain, report improvements in psychological well-being, emotional regulation, and self-awareness [36-38]. These benefits are perhaps reflective of the nonclinical settings in which the intervention takes place—often a library, community center, or virtual room—where emotional expression and a sense of belonging are created via the collective experience of literature reading. Notably, the values that underpin SR also closely align with trauma-informed frameworks, building around safety, choice, collaboration, trust, and empowerment as core principles of care [39,40]. In SR, participants can speak or stay silent, engage with the text directly or through its characters, and decide how much of their own story to bring into the room. These features make SR a conceptually strong strategy for adaptation to people living with and beyond gynecological cancer, for whom issues of control, identity, and safety are often central [41,42].

However, there is still uncertainty around the methodological and evaluative value of arts and health interventions due to poor study design, insufficient focus on feasibility studies, and a lack of consensus on how to measure their value [43,44]. Recommendations include incorporating mixed methods research to capture both the qualitative and quantitative impacts of arts and health interventions [45,46]. Feasibility and pilot studies are also thought of as foundations for later randomized controlled trials, providing critical evidence on design optimization, resource needs, and recruitment strategies [47,48]. Such preparatory work can offer insights often missing from efficacy trials and could inform policy, funding decisions, and the justification for larger-scale implementation.

Consistent with the Medical Research Council’s [49,50] guidance on explaining why an intervention works rather than exclusively on if it does, this feasibility study is underpinned by a realist evaluation (RE) approach [51]. RE seeks to explore what works, for whom, and in what circumstances through context-mechanism-outcome configurations. Specifically, “context” refers to the conditions under which the online SR may work, such as illness stage, prior interest in literature, or openness to discussing emotions. “Mechanism” relates to the intervention processes that may drive change, including emotional resonance with the literature or others in the group, self-reflection, or narrative reappraisal. Finally, “outcome” refers to the benefits that online SR may produce, including reduced distress; improved well-being or QoL; and feasibility measures such as attendance, engagement, and acceptability. Importantly, RE complements the study’s rationale because it recognizes that the intervention may be meaningful for some participants and less so for others depending on their unique cancer experiences, needs, and readiness to engage.

The primary study objective is to assess the feasibility and acceptability of a 6-week online SR intervention for women and gender-diverse people affected by gynecological cancers. The secondary objective is to explore the intervention’s preliminary individual-level effects on psychological well-being, distress, and QoL.

The intervention draws on the established face-to-face SR model developed by The Reader [35] but takes place within a virtual Microsoft Teams environment. Specifically, the intervention development followed 3 sequential steps: first, the lead author (ST-S) completed the mandatory 3-week Read to Lead facilitator program created by The Reader [35]. Training included guidance on facilitating open-ended literary discussions, using reflective pauses and questions, and maintaining respect and safety within a group environment. The latter aspect involves reiterating, at the start of each week, that sessions are not recorded and that any data handling will comply with the UK Data Protection Act 2018 and the General Data Protection Regulation.

Second, all selected literature was chosen either from The Reader’s anthology bank or in consultation with The Reader [35] (Multimedia Appendix 1). Texts with explicit references to cancer, illness, or death were excluded to avoid inadvertently influencing the content of the discussions or participants’ emotional responses.

Third, the digital adaptation of the sessions was refined in collaboration with and in response to feedback from a 1-hour patient and public involvement and engagement (PPIE) group; this informed both the content and online delivery format of the intervention. Specifically, in May 2024, a total of 6 community members were recruited via social media and asked to review and provide feedback on study materials and content and the appropriateness of online vs face-to-face delivery. Participants discussed the potential benefits of online sessions, including the lessening of cost and time burdens associated with traveling, as well as the potential widening of participation nationally and internationally. One PPIE participant was recruited to provide ongoing input throughout the research process. Their role includes supporting with participant recruitment, reflecting on qualitative data interpretation, and collaborating on the dissemination of findings. All contributions are reimbursed in line with National Institute for Health and Care Research guidance of £25 per person per hour (£1=US $1.35 as of August 7, 2026).

The finalized intervention model will consist of 6 weekly group sessions, each lasting 1 hour and delivered via Microsoft Teams. Sessions will be scheduled on the same day and time each week, to be confirmed with participants prior to intervention start. This decision will support a sense of continuity and allow participants to plan around existing commitments. Additionally, to preserve spontaneity, texts will be shared with participants via email 15 minutes before each session. Participants will be required to keep their cameras on to maintain a sense of group presence and connection; however, they will be free to contribute to discussions either verbally or via the chat function. Texts will be screen shared during sessions to ensure that all participants can easily follow along, thereby preserving the live, interactive presence of the literature. Session format and structure is shown in Table 1. Additionally, a TIDieR (Template for Intervention Description and Replication) checklist is provided as Checklist 1.

Up to 10 women and gender-diverse people aged 18 years or older diagnosed with a primary form of gynecological cancer will be invited to participate in the intervention. To be eligible, participants must not be receiving other psychological interventions at the time of recruitment. This exclusion reflects the potential for concurrent specialized therapies to confound interpretation of online SR’s preliminary individual-level effects on psychological distress, well-being, and QoL. The full eligibility criteria are shown in Textbox 1.

As this is not a full-scale trial, nor is the primary aim to evaluate the effectiveness of online SR, a formal sample size calculation was not required [52,53]. Instead, the target sample was determined based on 2 factors. First, single-case experimental design (SCED) methodology requires a minimum of 3 participants to demonstrate an experimental effect [54]. Second, the traditional SR model typically consists of 2 to 12 attendees [32]. Consequently, this feasibility study will aim to recruit between 4 and 10 participants and will not be designed or powered to evaluate the effectiveness of online SR; the absence of a comparator condition and the small sample size will preclude inferential conclusions about efficacy.

International study recruitment is planned from November 2025 to March 2026. Potential participants will be identified through clinician referral at patient identification centers within the South Central Regional Research Delivery Network and via study posters displayed in oncology waiting rooms. If required to meet recruitment targets, the study will also be promoted internationally, via cancer charities and social media platforms (ie, LinkedIn, X [formerly known as Twitter], and Facebook). Interested parties will contact the lead author (ST-S) directly and will be asked to complete a consent form and a screening and demographics questionnaire, as well as 3 weekly staggered baseline outcome measures (Multimedia Appendix 2). These data points will be collected via Qualtrics (Qualtrics International Inc), the same online platform where participants will indicate their availability for taking part in the online SR intervention.

The study uses a mixed methods, nonrandomized, multiple-baseline, within-subject design consistent with SCED methodology. The multiple baselines will be operationalized via 3 repeated preintervention assessments (at −2 weeks, −1 week, and week 0) to establish outcome measure stability. Afterward, participants will commence the 6-week intervention simultaneously. Participant or researcher blinding is not possible. Data collection points are shown in Table 2.

All questionnaire data will be collected via Qualtrics. Following submission of the consent form, participants will automatically receive a copy via the platform; copies may also be requested directly from the lead author via email. Participants will be assigned unique identification numbers at enrollment; data will be stored on password-protected university servers and handled in accordance with institutional data governance procedures.

Prior to the start of the online SR intervention, participants who require support with the Microsoft Teams platform will be offered an optional 15-minute tutorial covering how to join a meeting, use the chat and hand-raising functions, and manage audio and video settings. The tutorial will be delivered at a time convenient to each participant.

Participation is entirely voluntary, and participants are free to withdraw their consent at any point without needing to provide a reason; doing so will not impact their care or legal rights. If a participant who initially gave informed consent loses the ability to consent during the study (ie, due to progression of their illness), they will be withdrawn from the research. However, any data collected before the loss of capacity will be retained and included in the study unless the participant specifically requests complete data removal.

Withdrawal may take 2 forms: participants may inform the lead author (ST-S) of their withdrawal, with the option to either (1) cease all participation, including the intervention, questionnaires, exit survey, and interview; or (2) withdraw from the intervention only while continuing to complete questionnaires and/or the exit survey and/or the interview. Alternatively, participants may withdraw without notification; in this case, the lead author will attempt follow-up contact up to 2 times via email. An exit survey will be administered where possible to all participants who withdraw at whatever point withdrawal occurs to capture dropout reasons.

Quantitative and qualitative findings will be integrated to provide a comprehensive understanding of the intervention’s impact. Qualitative data will be used to clarify or expand upon the quantitative results within the RE framework [51]. Analyses will first be considered separately, with careful attention paid to how the findings align or diverge when forming overall conclusions.

Ethics approval was obtained from the University of Southampton (reference 101967) and the National Health Service Health Research Authority (reference 25/PR/0739), with study procedures to be conducted in accordance with the Declaration of Helsinki. Informed consent will be voluntary and ongoing, where participants may withdraw at any time without penalty or disruption to their care. Written consent will be obtained from all participants prior to enrollment via Qualtrics. Verbal informed consent will be collected and audio recorded via Microsoft Teams before the start of each interview. To thank participants for their time, a £50 Amazon voucher will be offered to those who attend at least 3 of 6 sessions, allowing participants several absences to account for potential illness, hospital appointments, or unforeseen circumstances.

Clinical safety will be monitored by clinical oncologists, cancer nurses, and care providers as part of the participants’ usual care. The lead author will be supervised by a clinical psychologist (AM), 2 health psychologists (MA-A and SK), and an academic supervisor (KS) throughout the study duration. If participants become distressed during the sessions, the lead author (ST-S) will attempt to first discuss their thoughts and feelings in the session. If participants decline, they will be offered a debrief after the end of the session, and the lead author will check in with them via email after the session. At the end of the online SR intervention, participants will automatically be offered signposting information to the Macmillan Information and Support Centre and their cancer clinical nurse specialist following the model of psychological care outlined in the National Institute for Health and Care Excellence guidelines [25]. Any instances of psychological distress will also be discussed in supervision with the team.

This study aims to evaluate a 6-week online SR intervention designed for women and gender-diverse people affected by gynecological cancers. Potential implications include that the digital, low-intensity, group-based online SR format may offer a novel mechanism to reach survivors who may be otherwise excluded due to residing in geographically remote areas, gender-biased care, financial constraints, and inability or reluctance to engage with formal psychological therapy. Demonstrating potential benefits could also justify future large-scale trials and inform service commissioning decisions, aligning with calls for early-phase experimental designs to bridge the gap between innovation and implementation [47,48].

The study’s use of a multiple-baseline SCED enables in-depth individual-level analysis despite the small sample size. Additionally, the study uses a mixed methods approach alongside an RE framework [51] to explore not only whether online SR is a feasible and acceptable intervention but also for whom and under what conditions. Finally, the intervention development was informed by PPIE from design to dissemination, ensuring that the online SR model was shaped alongside the people it aims to support.

However, consideration must be given to issues of equity and inclusivity in the design and delivery of the online SR intervention, including potential limitations in accessibility for individuals with lower digital literacy, limited educational opportunities, or neurodivergence and specific learning difficulties. Such factors may risk inadvertently excluding those who could benefit most from community-based psychosocial interventions. However, SR is intentionally designed to be open and participatory, accommodating a wide range of abilities and preferences; sessions emphasize listening as much as reading, and there is no expectation for participants to interpret texts in a particular way or even verbally contribute. This flexibility will allow individuals to engage with online SR at their own comfort level, supporting inclusion while preserving online SR’s ethos of shared, reflective connection through literature. Future refinement could explore the barriers to engagement among people who decline or withdraw from the online SR intervention to better understand their motivations and inform strategies to improve uptake and retention.

This feasibility study will be the first to examine online SR as an adjunctive psychosocial intervention for people affected by gynecological cancers. In doing so, the proposed intervention responds to a recognized gap in accessible, low-intensity psychosocial support for this population. Importantly, it may offer community-based peer support for those managing emotional distress who may prefer not to engage with or lack access to formal therapeutic support.

While the study is exploratory, it will offer foundational data on the acceptability, feasibility, and preliminary efficacy of online SR. Additionally, it will inform the potential intervention development components of a future, adequately powered, full-scale trial. Should the study demonstrate online SR to be feasible and acceptable, implications include having a scalable, low-cost model that could be embedded alongside existing survivorship pathways. Finally, its fully online delivery has potential to reach those facing geographical, financial, or psychological barriers to formal care, supporting more equitable access across diverse health system settings.