Expressive writing to address distress in hospitalized adults with acute myeloid leukemia: a pilot randomized clinical trial

Abstract

Purpose

Patients with acute myeloid leukemia (AML) experience significant distress. Expressive writing is an intervention designed to improve well-being by encouraging expression of emotions related to traumatic experiences. Expressive writing has been shown to be generally feasible and effective at improving the cancer experience but has not been examined in patients with recently diagnosed hematologic malignancies. We examined the feasibility of an expressive writing intervention for hospitalized patients with AML receiving induction chemotherapy.

Methods

Fifteen hospitalized AML patients were randomized to complete expressive writing or neutral prompts. Feasibility was defined as 80% of enrolled subjects completing the study. Participants completed validated questionnaires measuring depression, anxiety, resilience, rumination, and quality of life at baseline, completion of the second and fourth writing exercises, and 3 months after enrollment. Participants also completed post-writing surveys following the writing exercise to reflect on the experience.

Findings

We enrolled 15 participants and 8 of 15 subjects (53%) completed the study. Due to low enrollment, we examined the pre-to-post intervention changes, rather than comparing results across intervention arms. Pre-to-post intervention changes in the expected direction were seen at the second assessment for depression and resilience, at the fourth assessment for rumination, emotional well-being, and social well-being, and at the 3-month follow-up for anxiety and emotional well-being. Similar changes in patient-reported outcomes were also seen in the control condition. Participants who completed the intervention reported the experience was meaningful and were able to express their deepest thoughts and feelings, more so than participants in the control arm.

Conclusion

In our work, the expressive writing intervention was not found to be feasible. The trial was interrupted by the COVID-19 pandemic which likely impacted the feasibility. Future studies should aim to identify ways to make the intervention more accessible, such as developing an electronic application for expressive writing.

Keywords:

• Acute myeloid leukemia
• cancer
• expressive writing
• patient-reported outcomes
• supportive care

Acknowledgments

We are thankful to the late John F. Evans for guiding patients through the expressive writing intervention, and to Debra M. Davis for study enrollment and data collection. Also, we are grateful for the patients who participated in the research.

Author contribution

Study conception and design: TWL, KWH, TS. Material preparation, data collection, and analysis: TWL, KWH, SCL, MMN. Original draft: all authors. Manuscript revision: all authors. Funding acquisition: TWL, TS.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Duke University Health System Institutional Review Board (PRO#00100520).

Consent to participate

Informed consent was obtained from all individual participants included in the study.

Consent for publication

Patients signed informed consent to participate in the study, which included permission to publish.

Disclosure statement

Researchers declare the following conflicts of interest: TWL reports personal fees for consulting or advisory boards from AbbVie, Agios/Servier, AstraZeneca, Astellas, CareVive, BMS/Celgene, Flatiron, Genentech, GSK, Novartis, Pfizer, and Seattle Genetics; royalties from UpToDate; speakers bureau fees from Agios/Servier AbbVie, BMS/Celgene, and Incyte; grants and/or research contracts from the American Cancer Society, AstraZeneca, BMS, Jazz Pharmaceuticals, the NINR/NIH, and Seattle Genetics.

Data availability statement

The data has not been deposited to any central repository but can be made available upon request.

Additional information

Funding

The study was funded by a Cancer Control Pilot Grant from the Duke Cancer Institute.