The effects of expressive writing intervention in cancer patients and survivors: A rapid umbrella review

INTRODUCTION

Cancer, as a chronic disease, can be traumatic, affecting multiple facets of physical and psychological health and the quality of life (QOL) of cancer patients and survivors.^[1-3]

According to recent research, cancer patients’ willingness, ability, and opportunity to express cancer-related concerns and emotions may influence their adjustment to the stressors associated with cancer and cancer treatment, thereby affecting their psychological and physical health and QOL.^[2]

Pennebaker and Beal conducted the first expressive writing experiments in the fall of 1983 and discovered that healthy college students randomly assigned to write about traumas for 4 consecutive days, 15 min a day, ended up visiting the students’ health center at about half the rate of students in the control group over the next 6 months.^[4-6]

In 1985, a replication study led by Pennebaker et al. discovered reductions in health center visits and immune changes consistent with improved health over the next several years. Other laboratories replicated and failed to replicate the findings, with occasional criticisms of the methodology and theory.^[4-7]

Since then, numerous primary studies, systematic reviews, and meta-analyses have been conducted on the effects of expressive writing intervention (EWI) in various populations and methodologies, with significant deviations from Pennebaker and Beal’s original paradigm or their 1986 study.

Most primary studies conducted after Pennebaker and Beal’s, 1986, study significantly altered their original paradigm.^[8] For instance, several studies altered the setting variables and used home- or clinic-based settings; others altered the treatment variables, such as the number of sessions, the duration of each session, the time between sessions, and follow-up assessment; yet others altered other critical variables, such as the population studied, the type of outcome measures used, the type of instruction used, and the type of topics covered.

Meta-analyses and systematic reviews of expressive writing in healthy, clinical, and mixed populations revealed inconsistent and mixed findings. For instance, the first meta-analysis of expressive writing on a healthy college student population^[9] established that expressive writing has a moderate effect size on psychological and physical health (d = 0.47).

Later research on expressive writing in clinical populations (people with physical and psychological disorders) revealed a small effect (d = 0.19) on only physical symptoms.^[10]

In 2006, Frattaroli conducted a more extensive meta-analysis (n = 146) on diverse populations (student populations, clinical populations with physical and psychiatric disorders, and general populations) and discovered that expressive writing benefits an individual’s psychological health, physical health, and overall functioning, with an average Cohen effect value of d = 0.151. The study concluded that studies in this domain had a wide range of characteristics, many of which were associated with the size of the effect.

In addition, a narrative review of expressive writing studies revealed several beneficial effects on physical and psychological health, though the empirical evidence is generally equivocal.^[11]

In contrast, several systematic reviews and meta-analyses concluded that EWI had no beneficial effect on physical or psychological health outcomes in various populations.^[12-15] Apart from the equivocal and inconsistent findings of systematic reviews and meta-analyses, the literature review revealed a dearth of systematic reviews and meta-analyses on the EWI’s effects on cancer patients.

As a result, to the best of the authors’ knowledge, this is the first comprehensive review of systematic reviews and meta-analyses on EWIs in cancer patients and survivors.

MATERIALS AND METHODS

The present study followed the recommendations for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).^[16,17] The author created a narrative synthesis of the studies included.

RESULTS

The study selection process using the PRISMA flow diagram is described in [Figure 1].

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Figure 1:

Preferred reporting items for systematic reviews and meta-analyses flow diagram of study selection process.

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The initial search returned 8388 reports, of which 23 remained after duplicates were removed and screening steps were performed. After excluding 18 reports in the third step (eligibility assessment), five systematic reviews with or without meta-analyses published between 1986 and October 2019 met the inclusion criteria and were included in the present overview. The five studies included a total of 58 primaries (50 of which were analyzed).

Quality assessment through the AMSTAR tool^[20,21] revealed that 80% (n = 4) of the studies included had a moderate methodological quality, while 20% (n = 1) had a low methodological quality ranking, ranging from 4 to 8.

[Table 1] summarizes the characteristics of the studies included.

A total of 7235 (5771 after analysis) cancer patients or survivors were included in the five studies, with a mean sample size of 1447 (1154 of which were analyzed).

The majority (64%, n = 36) of primary studies examined breast cancer patients or survivors, while the remainder (36%, n = 20) examined other types of cancer (e.g., renal, prostate, colorectal, ovarian, and mixed cancer). A total of 80% (n = 4) of the studies included in this overview and 59% (n =3 3) of primary studies reported a writing task or topic, with the majority of primary studies (70%, n = 23) instructing EWI participants (experimental group) to disclose their emotions about their cancer (cancer trauma), 9% (n = 3) about other trauma (self-selected trauma), 6% (n = 2) wrote about other benefits, and 15% (n = 5) wrote about other topics.

In addition, the number of writing sessions varied, ranging from 1 to 6. The majority of primary studies included 4 (66%, n = 37) or 3 (23%, n = 13) sessions of writing.

The spacing of writing sessions varied as well, with daily or consecutive day writing sessions (28.5%, n = 16), weekly writing sessions (18%, n = 10), biweekly writing sessions (3.5%, n = 2), and triweekly writing sessions (16%, n = 9).

A total of 80% (n = 4) of the studies included and 78.6% (n = 44) of the primary studies reported a setting variable, with the majority of primary studies (84%, n = 37) having participants write in a non-laboratory setting (at home, in a clinic, or a mixed setting), while only 9% (n = 4) had laboratory-based designs and 7% (n = 3) had an unclear setting.

Furthermore, the control topic or task for the control group varied as well, with 61% (n = 34) of primary studies using neutral writing (facts about cancer, everyday activity, previous day activity, and health behavior), 30% (n = 17) using non-writing control topics (usual care), 4% (n = 2) using neutral non-emotional (trivial) writing, and 5% (n = 3) using other topics.

Moreover, post-intervention assessment time points varied, with 64% (n = 36) of primary studies reporting time points, from which 58% (n = 21) collected outcome data at two or more time points, 42% (n = 15) presented at a single time point, and 34% (n = 20) of the primary studies did not report time points.

A total of 80% (n = 4) of the studies included in this overview and 70% (n = 39) of primary studies reported the duration (time) of each session. Each session was also varied in length, with 87% of the primary studies lasting 20 min and the remaining (13%) lasting between 15, 15–20, 20–30, 30, and 90 min.

In terms of expressive writing’s overall effectiveness, 40% (n = 2) demonstrated no overall effectiveness, while 40% (n = 2) demonstrated only an effect on physical health outcomes. Only 20% (n = 1) of the remaining studies support expressive writing’s general effectiveness and 40% (n = 2) of the studies included found a moderating effect.

DISCUSSION

The current review of five systematic reviews and meta-analyses of EWI in cancer patients and survivors revealed mixed and inconsistent findings, with several of the studies included finding no evidence for EWI’s general effects in cancer patients and survivors. However, other studies included in this review discovered some benefits of EWI. Overall, the findings indicate that EWI trials had mixed or inconsistent effects and that some moderating variables moderated the effects of EWI in the cancer population.

The present overview’s null finding on expressive writing’s general effectiveness contrasts with earlier meta-analyses with healthy^[9] and mixed populations^[8] who found an overall effect for EWI. For example, Zachariae and O’Toole^[2] found no evidence for the general effects of EWI on any of the psychological or physical health outcomes in cancer patients and survivors. Although they discovered a moderating effect of social constraints in a subgroup of patients, Kupeli et al.^[22] also discovered no benefit for people with advanced disease (advanced cancer) from expressive writing.

However, Oh and Kim’s meta-analysis,^[3] found that EWI had a significant effect on physical health outcomes but not on psychological or cognitive outcomes in cancer patients, and Zhou et al.,^[6] found that EWI had a positive effect on physical health outcomes but not on psychological health outcomes in breast cancer patients, are consistent with findings reported by Frisina et al.^[10] who conducted a meta-analysis of expressive writing on clinical populations. They hypothesized that the small effect sizes and nonsignificant test of homogeneity observed in several studies included in this research synthesis could be explained by the small and heterogeneous samples used in those studies. In addition, they stated in an update to their meta-analysis findings that several methodological points, such as clinical heterogeneity in the populations of RCTs and the outcome combined, are worth discussing because they believe that they can alter the authors’ conclusions. Given this clinical heterogeneity, it is debatable whether the populations should be merged to produce a single effect size.^[23]

Only Tim^[24] discovered evidence for expressive writing’s general effectiveness in breast cancer patients, consistent with some earlier meta-analyses conducted on healthy and mixed populations.^[8,9]

Similarly, several of the moderating effects identified in this overview are consistent with Fratarroli’s^[8] findings from a large meta-analysis (n = 146) and several subsequent primary studies, including our 2 min single-session expressive writing study with traumatized undergraduates.^[25]

CONCLUSION

The present study reveals mixed and inconsistent findings for EWI and some moderating variables. These findings suggest significant clinical and methodological heterogeneity, deviation from Pennebaker and Beal’s original paradigm,^[5] and moderating variables may be responsible.

To replicate Pennebaker and Beal’s^[5] original findings on EWI, future individual studies should follow a similar design and methodology, and to achieve internal validity, future individual studies should follow a more rigorous methodology and homogeneity. Future systematic reviews and meta-analyses should be conducted using more homogeneous and rigorous primary trials with little or no statistical, methodological, or clinical heterogeneity.