Introduction
Expressive writing interventions (EWIs) have attracted significant interest in the field of oncology for the past 2 decades (Merz et al. Reference Merz, Fox and Malcarne2014). Expressive writing (EW) was originally conceptualized by Pennebaker and Beall (Reference Pennebaker and Beall1986). The original paradigm was first tested on healthy undergraduate students who wrote for 20 min over 4 days about their deepest emotions and thoughts related to traumatic or upsetting experiences, with the theory positing that the act of disclosing traumatic events helps to organize, assimilate, or give meaning to trauma, ultimately serving a cathartic function (Pennebaker and Chung Reference Pennebaker and Chung2007). Pennebaker and Beall then proposed that inhibiting behavior is psychologically stressful and that the effort to suppress trauma can result in rumination. Instead, writing allows for the release of these traumatic emotions to reduce psychological stress and improve well-being (Pennebaker and Chung Reference Pennebaker and Chung2007).
EW has been of interest for patients with cancer due to its potential to address emotional inhibition, a prevalent issue among oncology patients. Since the early 2000s, patients who frequently experience trauma from a cancer diagnosis and treatment have received EWIs (De Moor et al. Reference De Moor, Sterner and Hall2002; Rosenberg et al. Reference Rosenberg, Rosenberg and Ernstoff2002; Stanton et al. Reference Stanton, Danoff-Burg and Sworowski2002; Walker et al. Reference Walker, Nail and Croyle1999; Zakowski et al. Reference Zakowski, Ramati and Morton2004). Emotional inhibition in these patients can lead to adverse psychological outcomes, a gap EW may fill by providing an outlet for emotional expression11. The mechanisms underlying EW, such as catharsis, cognitive restructuring of trauma, emotional regulation, and modulation of habituation to trauma-related emotions, are especially relevant to the experiences of patients with cancer (Chu et al. Reference Chu, Wu and Lu2020; Lepore et al. Reference Lepore, Revenson and Roberts2015; Pennebaker and Beall Reference Pennebaker and Beall1986). EW also offers patients with cancer diagnosis the opportunity to safely explore and process cancer-related thoughts and feelings in a private setting, free from the possibility of receiving unsupportive feedback, thus promoting open expression and emotional release without inhibition (Chu et al. Reference Chu, Wu and Lu2020). EWIs facilitate self-regulation skills, including increased confidence, stress management, and regulation of thoughts and behaviors, to restore a sense of perceived control often lost during cancer diagnosis and treatment (Chu et al. Reference Chu, Wu and Lu2020; Lepore et al. Reference Lepore, Revenson and Roberts2015; Zachariae and O’Toole Reference Zachariae and O’Toole2015). Through expressive flexibility, patients learn to adjust their emotional responses depending on the context, to engage or disengage from negative emotions as needed (Kupeli et al. Reference Kupeli, Chatzitheodorou and Troop2019). Additionally, EWIs promote schema-building by enabling patients to reflect, process, and reframe their experiences, integrating negative events into a self-schema (Chung and Pennebaker Reference Chung and Pennebaker2011; Low et al. Reference Low, Stanton and Danoff-Burg2006). While writing may lead to distress, it ultimately cultivates greater self-knowledge and psychological resilience (Pennebaker and Beall Reference Pennebaker and Beall1986)
Despite several meta-analyses and systematic reviews investigating the impact of EWIs in cancer care, variations in intervention type and length, cancer type, and intervention assessment measures remain a barrier to their integration into clinical practice. Additionally, recent reviews have primarily examined quantitative assessments of EWI interventions without a synthesis on patient experiences with EWI from qualitative studies (Abu-Odah et al. Reference Abu-Odah, Su and Wang2024; Kupeli et al. Reference Kupeli, Chatzitheodorou and Troop2019; Merz et al. Reference Merz, Fox and Malcarne2014; Zachariae and O’Toole Reference Zachariae and O’Toole2015). Hence, this scoping systematic review bridges existing gaps in the literature by examining quantitative and qualitative studies on EWIs for patients with cancer to inform ongoing work to tailor EWIs for this population.
Methods
A scoping systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines was conducted (Tricco et al. Reference Tricco, Lillie and Zarin2018). A scoping systematic review is relevant for this type of investigation because it allows for the inclusion of both qualitative and quantitative studies. Since EW is an intervention that lends itself to both empirical and narrative outcomes, the inclusion of all types of studies is paramount to encapsulate patient-reported qualitative and quantitative benefits of EWIs (Mak and Thomas Reference Mak and Thomas2022; Peters et al. Reference Peters, Marnie and Tricco2020).
Search strategy
We conducted a comprehensive literature search via MEDLINE/PubMed and Web of Science to identify relevant articles published over the last 10 years (January 1, 2015 to February 24, 2025). The literature search included Medical Subject Headings (MeSH) and related text and keyword searches focusing on terms to describe writing interventions in cancer populations. The initial search was conducted on August 2, 2021, yielding 19 studies, a second search was conducted on August 2, 2024, yielding 21 studies, and a third search was conducted on February 24, 2025, yielding 28 studies. We combined keywords related to the intervention (“expressive writing” or “therapeutic writing”) with the keywords related to the patient population (“cancer” or “oncology”). Both quantitative and qualitative studies were considered.
Study selection
Figure 1 illustrates the selection process. Studies were independently screened by the authors J.W. and C.S.P. Disagreements were resolved by collaborative reanalysis of the studies in question.
Figure 1. PRISMA selection of studies.
Inclusion and exclusion criteria
Studies included in the review had some form of EWI during the cancer care continuum. Studies included adult patients who were 18 years or older, underwent virtual and/or in-person individual interventions, experienced any malignancy, and were at any point across the cancer care continuum (including at the time of diagnosis, pre-treatment, post-treatment, in remission, and end-of-life). We excluded studies if the study subjects were caregivers or staff, involved group-based writing interventions, if there was no English version available, or if the articles were dissertations, conference proceedings, or otherwise unavailable.
Results
Study selection
There were 24 quantitative studies and 4 qualitative studies examined. Figure 1 illustrates the selection process. A total of 396 articles were screened for inclusion. Of these, 129 duplicate records were removed. Abstract screening of the remaining 396 yielded 40 articles for full-text assessment of eligibility, and this yielded 28 articles for inclusion in this scoping review. Table 1 provides the full details of each study and its findings. All studies included were written in English. The majority were conducted in the USA (42.8%), with the remainder of the studies conducted in China (28.6%), Australia (14.3%), Denmark (3.6%), Italy (3.6%), Indonesia (3.6%), and the Netherlands (3.6%) (Table 1).
Table 1. Studies (N = 28) reporting experimental trials of expressive writing interventions in cancer patients
Participant characteristics
The 28 included studies examined EWIs in a total of 3527 patients, with individual study sizes ranging from 7 to 507 patients. Twenty studies included only women participants (71.4%). Of the studies conducted in the USA (n = 1089 patients), 46.8% of patients were White, 2.7% were Black, 42.8% were Asian, 3.2% were Latino, and 4.1% identified as Other. Notably, 12 studies only included Asian (Chinese) participants (n = 1235), 2 studies only included Australian participants, and 3 studies only included countries of origin (Danish, Indonesian, and Italian) (Table 1). Most studies (71.4%) were conducted on patients with breast cancer, 2 studies on patients with renal cancer (7.1%), 1 study on colorectal cancer (3.6%), 1 study on head and neck cancer (3.6%), 1 study on acute myeloid leukemia (AML), and 1 study on patients with cancer in general without a specific type designated (3.6%).
Intervention characteristics
Our examined studies described intervention characteristics (e.g., delivery setting, delivery modality) to a varying extent.
Intervention delivery setting
Intervention delivery settings included patients’ homes (71.4%, n = 20), the hospital for cancer treatment (21.4%, n = 6), patient preference of home or clinic (3.6%, n = 1), or patient preference of home or research office (3.6%, n = 1). While most of the interventions were self-administered, some entailed study research assistant phone support in addition to self-administration.
Intervention delivery modality
Seventy-five percent (n = 21) of interventions were delivered via pen-and-paper, 14.3% (n = 4) were delivered via an online platform, and 10.7% (n = 3) were delivered via pen-and-paper or online based on patient preference. Pen-and-paper formats typically entailed a simple bound journal with blank pages for patients to keep. Online platforms consisted of websites designed by the research team in which patients anonymously typed their journal entries.
Writing prompts
Most studies (16/28, 57.1%) utilized an emotional disclosure prompt, where participants wrote about their deepest and darkest feelings concerning their cancer and other highly upsetting experiences (Table 1). A similar prompt was utilized by 5 studies (5/28, 17.8%) where they asked participants to write about their body. Four studies utilized the online EWI My Changed Body (MyCB), which is a web-based writing intervention program that uses self-compassion and EW to address adverse body image alterations following cancer treatment (Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Mifsud et al. Reference Mifsud, Pehlivan and Fam2021; Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016; Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018). One study used a program called Expand Your Horizon (EYH), which is a writing-based intervention in which participants spend 15 min per session reflecting on and writing about the value of certain body functions (Brkic et al. Reference Brkic, Prichard and Daly2024). For some studies, the control group utilized cancer facts (6/28, 21.4%) or daily facts prompts (8/28, 28.6%), which instructed patients to write about facts relevant to their cancer experience or write about a non-disclosing topic about their daily activities, respectively. A small minority of studies (8/28, 28.6%) utilized a self-regulation or enhanced self-regulation prompt, where the patients either wrote about their deepest feelings at week 1, stress and coping at week 2, and finding benefits at week 3, or wrote about stress and coping at week 1, deepest feelings at week 2, and finding benefits at week 3, respectively. Two studies utilized a positive thinking/psychology prompt where the patients wrote about the positive aspects of their cancer experience (Lu et al. Reference Lu, Dong and Wu2019; Ren et al. Reference Ren, Meng and Yin2025).
Timing of intervention
Interventions were delivered after active treatment (19/28, 67.9%), during active treatment (7/28, 25.0%), and at the point of diagnosis (2/28, 7.2%). Of those studies that confined intervention to after active treatment, the time for recruitment ranged from 4 weeks to 5 years. Of the studies that intervened at the point of diagnosis, one study specified within 1 year of diagnosis, while another did not offer a specific time frame other than “newly diagnosed.”
Timeline of assessments
Studies used different time points for data collection and assessments. While all studies obtained pre-intervention assessments, follow-up assessments were completed at varying time points either proximal to the intervention completion or later such as 10 months post-intervention. Of the 24 quantitative studies, 6 had follow-up assessments at 1, 3, and 6 months, 2 had follow-up at 1, 4, and 10 months, and the rest had variations in follow-up time points (Table 1).
Study outcome measures
Researchers used a myriad of surveys and scales to assess the impact of their intervention on patients. We broadly grouped them into categories pertaining to psychosocial outcomes, functional outcomes, and medical outcomes (Table 2). Twelve studies assessed health-related QOL (Ji et al. Reference Ji, Lu and Wang2020; La Marca et al. Reference La Marca, Maniscalco and Fabbiano2019; Lepore et al. Reference Lepore, Revenson and Roberts2015; Lu et al. Reference Lu, Wong and Gallagher2017, Reference Lu, Gallagher and Loh2018, Reference Lu, Dong and Wu2019; Nakatani et al. Reference Nakatani, Locke and Herring2024; Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025; Sohl et al. Reference Sohl, Dietrich and Wallston2017; Tan et al. Reference Tan, Cai and Wen2025; Wang et al. Reference Wang, Geng and Ji2020; Wu et al. Reference Wu, Liu and Zheng2021), and many other studies focused on other physical symptoms, including sleep (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Lepore et al. Reference Lepore, Revenson and Roberts2015; Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Ren et al. Reference Ren, Meng and Yin2025; Tan et al. Reference Tan, Cai and Wen2025), fatigue (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Tan et al. Reference Tan, Cai and Wen2025), lymphedema (Milbury et al. Reference Milbury, Lopez and Spelman2017), and pain (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Lepore et al. Reference Lepore, Revenson and Roberts2015; Melissant et al. Reference Melissant, Jansen and Eerenstein2021). Many of the studies assessed psychosocial outcomes as 9 studies focused on depressive symptoms (Brkic et al. Reference Brkic, Prichard and Daly2024; Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Lepore et al. Reference Lepore, Revenson and Roberts2015; Lu et al. Reference Lu, Wong and Gallagher2017; Ren et al. Reference Ren, Meng and Yin2025; Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025; Tan et al. Reference Tan, Cai and Wen2025; Wang et al. Reference Wang, Li and Xu2022; Widanti et al. Reference Widanti, Kusumadewi and Ismanto2024), 8 studies looked at anxiety/stress (Brkic et al. Reference Brkic, Prichard and Daly2024; La Marca et al. Reference La Marca, Maniscalco and Fabbiano2019; Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Nakatani et al. Reference Nakatani, Locke and Herring2024; Ren et al. Reference Ren, Meng and Yin2025; Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025; Tan et al. Reference Tan, Cai and Wen2025; Widanti et al. Reference Widanti, Kusumadewi and Ismanto2024), 4 studies examined self-compassion or self-efficacy (Chu et al. Reference Chu, Wong and Lu2019; Lu et al. Reference Lu, Yeung and Tsai2023; Mifsud et al. Reference Mifsud, Pehlivan and Fam2021; Wu et al. Reference Wu, Liu and Zheng2021), and 5 studies looked at body image distress (Chu et al. Reference Chu, Wong and Lu2019; Li et al. Reference Li, Gao and Li2025; Nakatani et al. Reference Nakatani, Locke and Herring2024; Wang et al. Reference Wang, Li and Xu2022; Wu et al. Reference Wu, Liu and Zheng2021). Some studies also developed their own tools to assess certain outcomes that did not have pre-existing scales specific to their desired outcome. These assessed the extent of meaningful, personal, and emotional writing participants wrote (Lepore et al. Reference Lepore, Revenson and Roberts2015), participants’ state of distress (Brkic et al. Reference Brkic, Prichard and Daly2024), and participant reflections (Widanti et al. Reference Widanti, Kusumadewi and Ismanto2024).
Table 2. Surveys used for outcome measures
Benefits of EWIs
Quantitative studies
Of the 24 quantitative studies, 87.5% (n = 21) highlighted potential benefits such as improved quality of life (QOL) and health-related symptoms (Table 1). Major outcomes positively impacted by EWI in patients with cancer from the studies included QOL, global well-being, physical symptoms, including sleep and fatigue, body image, and self-efficacy/compassion.
Quality of life
Twelve studies focused on the impact of EWIs on QOL. Of the 12 studies that assessed the impact of an EWI on QOL, 8 showed a positive significant association between EWIs and QOL (Ji et al. Reference Ji, Lu and Wang2020; La Marca et al. Reference La Marca, Maniscalco and Fabbiano2019; Lu et al. Reference Lu, Wong and Gallagher2017, Reference Lu, Gallagher and Loh2018, Reference Lu, Dong and Wu2019; Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025; Tan et al. Reference Tan, Cai and Wen2025; Wang et al. Reference Wang, Li and Xu2022), and 4 showed a negative or no association between EWIs and QOL (Lepore et al. Reference Lepore, Revenson and Roberts2015; Nakatani et al. Reference Nakatani, Locke and Herring2024; Sohl et al. Reference Sohl, Dietrich and Wallston2017; Wu et al. Reference Wu, Liu and Zheng2021). An example of a study highlighting a positive association between EWIs and QOL was done by LaMarca and colleagues who used a 2-armed RCT in 71 patients randomized to an emotional disclosure EWI or cancer facts control group to show that a Pennebaker-modeled EWI improved health-related QOL for patients with cancer when compared to control (d = .31) (La Marca et al. Reference La Marca, Maniscalco and Fabbiano2019). Wang and colleagues conducted a 2-arm RCT with 82 patients with breast cancer randomized to an emotional disclosure EWI or control group and showed that EWI significantly improved QOL at 2 weeks when compared to the control group (p < .05) (Wang et al. Reference Wang, Li and Xu2022). Lastly, Tan and colleagues conducted a 2-arm RCT with 76 patients with breast cancer randomized to an emotional disclosure EWI and routine care control group and found that compared to the control group, the EWI group exhibited significant improvements in QOL (p <.05) (Tan et al. Reference Tan, Cai and Wen2025).
An example of a study that found a negative association between EWI and QOL was done by Wu and colleagues, who conducted a 2-arm RCT with 112 patients with breast cancer, showing that QOL significantly decreased over time for both the experimental and control groups (p < .05), and there was no significant difference in QOL between the 2 groups (p > .05) (Wu et al. Reference Wu, Liu and Zheng2021). Interestingly, Sohl and colleagues conducted a 2-armed RCT with 104 patients with breast cancer randomized to an emotional disclosure EWI or daily facts control group and found that EWIs did not provide statistically significant main or interaction impacts on any QOL measure (p > .05). However, EWIs were more effective for improving QOL in women who were higher on scales of dispositional optimism (LOT-R) (p = .017), lower on scales of avoidant behavior (IES-avoidance) (p = .007), and had less time since lymphedema diagnosis (p = .003) (Sohl et al. Reference Sohl, Dietrich and Wallston2017).
Well-being globally
Eight studies found that EWI led to significantly improved global well-being (e.g., depression (Brkic et al. Reference Brkic, Prichard and Daly2024; Nakatani et al. Reference Nakatani, Locke and Herring2024; Ren et al. Reference Ren, Meng and Yin2025), anxiety, and perceived stress (La Marca et al. Reference La Marca, Maniscalco and Fabbiano2019; Li et al. Reference Li, Gao and Li2025; Lu et al. Reference Lu, Yeung and Tsai2023; Nakatani et al. Reference Nakatani, Locke and Herring2024; Ren et al. Reference Ren, Meng and Yin2025), emotional/social/physical well-being (Lu et al. Reference Lu, Wong and Gallagher2017; Tan et al. Reference Tan, Cai and Wen2025), PTSD symptoms (Chu et al. Reference Chu, Wong and Lu2019; Ren et al. Reference Ren, Meng and Yin2025), and resilience (Nakatani et al. Reference Nakatani, Locke and Herring2024)). For example, Ren and colleagues conducted a 2-arm RCT with 82 patients with epithelial ovarian cancer randomized to a positive psychology EWI or a routine care control group and showed that compared to the control group, the experimental group had greater reductions in depression (mean ± SD: 42.10 ± 3.86 vs. 48.75 ± 4.62, p < .001) (Ren et al. Reference Ren, Meng and Yin2025). Li and colleagues conducted a 3-arm RCT with 138 patients with head and neck cancer receiving radiotherapy randomized to a benefit finding EWI, daily facts EWI, or routine care control group and found that both writing groups reduced depression and anxiety when compared to controls (p < .05). Tan and colleagues also observed significant improvements in physical well-being for their EW group when compared to control, in addition to the improvements in QOL mentioned above (Tan et al. Reference Tan, Cai and Wen2025).
PTSD symptoms were also improved with EWIs in 2 studies. Chu and colleagues conducted a 3-arm RCT with 96 patients with breast cancer randomized to a self-regulation EWI, emotional disclosure EWI, or cancer facts control group and found that among patients with low acculturation, PTSD symptoms were less severe in the self-regulation and cancer-fact groups when compared to the emotional disclosure EWI (p < .05) (Chu et al. Reference Chu, Wong and Lu2019). In Ren and colleagues’ two-arm RCT with 82 patients with epithelial ovarian cancer, they also found that the positive psychology EWI had significantly higher post-traumatic growth (PTGI: 73.43 vs. 63.19, p < 0.001) when compared to routine care controls (Ren et al. Reference Ren, Meng and Yin2025).
Nakatani showed that EW significantly enhanced resilience in their 2-arm randomized pilot study with 46 patients with AML randomized to an emotional disclosure EWI and daily facts writing control, where transient yet significant improvements in resilience were present for the EW group compared to controls (no p values provided) (Nakatani et al. Reference Nakatani, Locke and Herring2024).
Physical symptoms including sleep and fatigue
Five studies highlighted EWI’s positive impact on physical symptoms (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Milbury et al. Reference Milbury, Lopez and Spelman2017), sleep (Li et al. Reference Li, Gao and Li2025; Milbury et al. Reference Milbury, Lopez and Spelman2017; Narayanan et al. Reference Narayanan, Milbury and Wagner2020), and fatigue (Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025). Milbury and colleagues conducted a 2-arm RCT with 277 patients with renal cell carcinoma randomized to an emotional disclosure EWI or a daily fact-writing control group and found that compared to controls, the EWI group had significant improvements in cancer-related symptoms (p < .05) and sleep disturbances (p < .005) (Milbury et al. Reference Milbury, Lopez and Spelman2017). Jensen-Johansen and colleagues conducted a 2-arm RCT with 507 patients with breast cancer randomized to an emotional disclosure EWI or daily facts-writing control group and found that low-alexithymia women in the EW group showed larger decreases in general practitioner telephone calls over time than both high-alexithymia women and controls (p = .006) (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018). In Shin-Cho and colleagues’ 2-arm RCT, they showed that the EWI group had significantly reduced fatigue (d = −.64) when compared to the daily facts control group (Shin-Cho et al. Reference Shin-Cho, Choi and Dawkins-Moultin2025). Li and colleagues’ 3-arm RCT also showed that when compared to routine care controls, the benefit-finding EWI group showed improved sleep quality (p < .01) (Li et al. Reference Li, Gao and Li2025). Interestingly, Narayanan and colleagues conducted a novel 2-arm RCT, examining the religious engagement in EW for 277 patients with renal cell carcinoma randomized into an emotional disclosure EWI or a daily facts control group, and found that religious engagement was negatively associated with fatigue (r = 0.21; p < 0.05), and negative religious content (less religious content) was significantly positively associated with poor sleep (r = 0.23; p < 0.05) (Narayanan et al. Reference Narayanan, Milbury and Wagner2020).
Body image, self-efficacy/compassion
Four studies found that EWI’s positively impacted body image perception (Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018; Widanti et al. Reference Widanti, Kusumadewi and Ismanto2024) and self-efficacy/compassion (Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Mifsud et al. Reference Mifsud, Pehlivan and Fam2021; Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018). For example, Widanti and colleagues conducted a 2-arm RCT with 46 patients with breast cancer randomized to a body image EWI and free writing control group and found that the body image EWI group showed a significant reduction in body image distress (mean reduction: 1.74 ± 1.14, p = .000), compared to the control group (0.35 ± 0.57, p = .011), with EW demonstrating a 41.6% effect size (p = .000) with sustainment of these improvements at 3-month follow-up (Widanti et al. Reference Widanti, Kusumadewi and Ismanto2024). Sherman and colleagues conducted a 2-arm RCT with randomization of 304 patients with breast cancer into a MyCB EWI or distressing event EWI control group and found that participants who received MyCB reported significantly less body image distress (p = .035), greater body appreciation (p = .004), and self-compassion (p = .001) than the control group (Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018). Melissant and colleagues conducted a 2-arm RCT with 233 patients randomized to a MyCB EWI or routine care control group and found that the MyCB group showed significant improvement in self-compassion (p = .003) (Melissant et al. Reference Melissant, Jansen and Eerenstein2021). Additionally, Mifsud and colleagues ran a 3-arm RCT with 79 patients with breast cancer randomized to a MyCB EWI, MyCB + meditation, or distressing event EWI control group and found that self-compassion and positive affect increased for MyCB compared to the EWI control group (p = .002 and .046, respectively), and at 1-month, body image distress decreased across all conditions (p = .02); self-compassion increased and anxiety decreased for MyCB + M compared to MyCB EWI and the EWI control group (p = .002 and .001, respectively) (Mifsud et al. Reference Mifsud, Pehlivan and Fam2021).
Modifiers of EWI benefits
Additionally, 11 studies identified modifier effects on outcomes as follows: the cancer fact, self-regulation, positive thinking, and self-compassion EW prompts, high optimism, low avoidance, early cancer survivorship, having social support and more severe depressive symptoms, low alexithymia, lymphedema status, self-compassion, low acculturation, social and cultural contexts, religious engagement and coping, and meditation (Chu et al. Reference Chu, Wong and Lu2019; Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Ji et al. Reference Ji, Lu and Wang2020; Lu et al. Reference Lu, Dong and Wu2019, Reference Lu, Gallagher and Loh2018, Reference Lu, Wong and Gallagher2017; Mifsud et al. Reference Mifsud, Pehlivan and Fam2021; Milbury et al. Reference Milbury, Lopez and Spelman2017; Narayanan et al. Reference Narayanan, Milbury and Wagner2020; Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018; Sohl et al. Reference Sohl, Dietrich and Wallston2017). Three studies examined potential additional modifiers and found them to be noncontributory, including sex, social constraints, repressive coping, rumination, writing topic, and writing dosage (Jensen-Johansen et al. Reference Jensen-Johansen, O’Toole and Christensen2018; Lepore et al. Reference Lepore, Revenson and Roberts2015; Wu et al. Reference Wu, Liu and Zheng2021) (Table 3).
Table 3. Modifiers of EWI impact on quality of life (QOL) or health-related outcomes
Qualitative studies
Four qualitative studies were included in our review, with a total of 93 patients. Of these studies, 1 was conducted in the USA and Norway (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016), 1 was conducted in the USA (Warmoth et al. Reference Warmoth, Cheung and You2017), 1 was conducted in Australia (Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016), and 1 was conducted in China (Wang et al. Reference Wang, Geng and Ji2020). Three of the studies analyzed the patients’ writings (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016; Wang et al. Reference Wang, Geng and Ji2020; Warmoth et al. Reference Warmoth, Cheung and You2017), and 1 study examined the feasibility of providing an EWI through an online format (MyCB) (Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016). The insights from these qualitative studies highlight mechanisms by which EWIs support patients with cancer. Three themes emerged from the synthesis of these studies: (1) EWIs facilitate the narrative reconstruction of cancer-related trauma, by enabling the processing of existential distress through the act of storytelling; (2) disclosure is shaped by cultural norms, where the psychosocial context of patients’ environments shape what they disclose through their writings; and (3) the delivery format of interventions matters, as online platforms like MyCB help dismantle barriers to emotional expression in cultural environments that prioritize emotional restraint. Overall, these qualitative studies support that the therapeutic value of EWIs extends beyond emotional release by validating patients’ agency, such as reasserting control over treatment decisions (Wang et al. Reference Wang, Geng and Ji2020) or reclaiming bodily autonomy post-mastectomy (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016). These findings uncover the importance of adapting EWIs cross-culturally (Wang et al. Reference Wang, Geng and Ji2020; Warmoth et al. Reference Warmoth, Cheung and You2017) and tailoring prompts (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016) and mechanisms of delivery (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016; Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016) to help navigate the sociocultural barriers that prevent patient disclosure.
Narrative reconstruction
EWIs enable patients with cancer to reconstruct overwhelming traumatic cancer experiences into coherent narratives through the process of storytelling. This exercise helps to foster agency, psychological resilience, and reshape the meaning of the experiences that patients with cancer go through. For example, Gripsrud and colleagues conducted a qualitative intervention feasibility study of an emotional disclosure EWI with 7 post-mastectomy patients with breast cancer in the USA and Norway and found that breast cancer survivors utilized writing through the EWI to convert “impressions into expressions,” restructuring situational distress into survivorship-affirming stories (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016). One patient expressed that the EWI enabled her to let her thoughts “reside somewhere else,” helping her to develop agency in reducing her cognitive load. Additionally, Wang and colleagues conducted a qualitative intervention study with 44 patients with breast cancer in mainland China and found that their self-regulation EWI helped survivors to process existential distress, such as the reconciliation of mastectomy decisions in the cultural contexts of femininity (Wang et al. Reference Wang, Geng and Ji2020). One patient wrote, “As long as it would save my life, any sacrifice was worth it,” highlighting reconstruction of loss or sacrifice into agency. EWIs are not solely emotional vectors for patients with cancer, but tools that help reconstruct cancer-related traumas and provide survivorship-affirmation.
Cultural disclosure norms
Cultural norms and values often inform how and to whom patients disclose emotions and experiences. As such, EWIs must be culturally adaptive to enable safe disclosure for patients with cancer. For example, Warmoth and colleagues conducted a qualitative emotional disclosure EWI study with 27 Chinese immigrant patients with breast cancer in the USA and found that the EWI provided an avenue of disclosure that Confucian and collectivist cultural values may inhibit (Warmoth et al. Reference Warmoth, Cheung and You2017). One patient wrote, “I didn’t even tell my husband and daughter. I was afraid they would be distressed. So, I was the only one who knew this (breast cancer diagnosis).” This patient feared being perceived as a burden, a common concern fueled by cultural stigma around cancer as a “punishment” or “bad luck”(Warmoth et al. Reference Warmoth, Cheung and You2017). Similarly, in Wang and colleagues’ study with 44 Chinese mainland breast cancer survivors further supports these cultural barriers, as one patient wrote that “I didn’t tell my mother about the diagnosis because I was worried that she could not accept the truth. I didn’t tell my son about the diagnosis because I didn’t want him to worry about it. I didn’t tell my husband about the diagnosis because I didn’t want to burden him. Sometimes, I felt like I was wearing a mask to live” (Wang et al. Reference Wang, Geng and Ji2020). This cultural barrier contrasts with patients in Western cultures, where participants openly discussed grief and body image struggles without familial cultural restraints. For example, in Gripsrud and colleagues’ study with breast cancer survivors in the USA and Norway, one breast cancer survivor said, “I think I’m probably going to let my family read it, maybe put… what I’ve written into a little book or diary, and have them read it,” suggesting that familial cultural norms are not as apparent in this Western environment. This stark contrast highlights how cultural norms can impact disclosure in patients with cancer and underscores the importance of implementing EWIs that respect cultural differences (e.g., framing prompts around collectivist familial roles rather than individualism or conducting the EWI in patients’ native language) (Wang et al. Reference Wang, Geng and Ji2020).
Intervention delivery format
Home-based EWIs, especially on online platforms, help dismantle cultural barriers to emotional disclosure, particularly in contexts where face-to-face disclosure may be stigmatized. In Przezdziecki and colleagues’ qualitative self-regulation EWI acceptability study with 15 patients with breast cancer in Australia, they utilized the web-based EWI “MyCB,” and patients appreciated the privacy it provided for their disclosure (Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016). One patient noted, “I could express things on paper I wouldn’t tell my family,” highlighting how the digital platform provided evasion from cultural punishment against public vulnerability. Additionally, health professionals reviewing the web-based writings noted its ability to circumvent potential stigma, as patients could anonymously write without fear of judgment, a common cultural barrier impacting emotional disclosure. Similarly, Wang and colleagues found that the mainland Chinese breast cancer survivors in their study preferred home-based writing and structured prompts, as it helped to avoid public emotional displays and to express their fears safely (Wang et al. Reference Wang, Geng and Ji2020). In sum, EWIs may be culturally adapted to enhance their therapeutic effect and promote emotional disclosure for patients from all cultural backgrounds.
Discussion
This scoping review synthesized findings from EWIs in 28 studies of 3527 patients with cancer, with quantitative and qualitative data as well as potential associations between EWIs and outcomes. Twenty-four studies examined and reported the association between EWIs and clinical outcomes (e.g., symptoms, psychological distress, and QOL) using validated instruments and quantitative assessments pre-post intervention, while 4 studies used qualitative methods to provide insights into patient experiences with EWIs (Tables 1 and 2). While most studies suggest potential benefits of EWIs for patients with cancer, further longitudinal research is needed to establish the overall impact of EWIs in these populations.
Although quantitative and qualitative studies highlight the potential benefit of EWIs for patients with cancer, the heterogeneity of these studies makes it difficult to translate these findings into clinical practice. For example, studies assessed the same outcomes with different validated instruments such as QOL being assessed with the Cancer Quality of Life Questionnaire (QLQ-C30) (Aaronson et al. Reference Aaronson, Ahmedzai and Bergman1993) in 1 study (Lepore et al. Reference Lepore, Revenson and Roberts2015), Functional Assessment of Cancer Therapy – Breast scale (Wan et al. Reference Wan, Zhang and Yang2007) (FACT-B) (Ji et al. Reference Ji, Lu and Wang2020; Lu et al. Reference Lu, Dong and Wu2019; Sohl et al. Reference Sohl, Dietrich and Wallston2017; Tan et al. Reference Tan, Cai and Wen2025; Wu et al. Reference Wu, Liu and Zheng2021) or Functional Assessment of Cancer Therapy general scale (FACT-G) (Cella and Tulsky Reference Cella and Tulsky1993) in 8 studies (Lu et al. Reference Lu, Gallagher and Loh2018, Reference Lu, Wong and Gallagher2017; Nakatani et al. Reference Nakatani, Locke and Herring2024), QOL Instruments for Patients with Breast Cancer (QLICP-BR) (Wan et al. Reference Wan, Yang and Tang2009) in 1 study (Wang et al. Reference Wang, Li and Xu2022), and European Organization for Research and Treatment of Cancer Head and Neck Cancer Module (EORTC QLQ-HN43) (Aaronson et al. Reference Aaronson, Ahmedzai and Bergman1993) in 1 study (Melissant et al. Reference Melissant, Jansen and Eerenstein2021). Additionally, the method of conducting EWIs varies significantly between the studies in this review, as differences in the timing of intervention with ongoing treatment for patients, timeline of assessing outcomes, intervention modality and settings were present. Heterogeneity in the methodology of RCT’s assessing the benefits of EWIs in patients with cancers underscored the conclusions presented by the 2 previous reviews conducted on EWIs and their impacts on patients with cancer (Merz et al. Reference Merz, Fox and Malcarne2014; Zachariae and O’Toole Reference Zachariae and O’Toole2015). Additionally, some potential benefits of EWI’s including their ability to provide safe emotional disclosure, as supported by the qualitative data in this study (Gripsrud et al. Reference Gripsrud, Brassil and Summers2016; Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016; Wang et al. Reference Wang, Geng and Ji2020; Warmoth et al. Reference Warmoth, Cheung and You2017), are not easily captured by validated measures, highlighting the importance of qualitative studies within this topic.
The demographics of patient populations in recent studies are limited, and future interventions must foster more inclusivity. Cancer-risk behaviors are more prevalent in men than women, and men are more likely to die from cancer (Cook et al. Reference Cook, McGlynn and Devesa2011; Pinkhasov et al. Reference Pinkhasov, Wong and Kashanian2010). Despite these gender differences, the studies in this scoping review rarely included men or the cancers that predominantly impact men. Sixty-six percent of the studies analyzed, encompassing 16 of the 24 quantitative studies, and all 4 of the qualitative studies focused on breast cancer and only included women. Traditional male gender norms inhibit the emotional expression in men with cancer (Hoyt Reference Hoyt2009), and Smyth’s meta-analysis theorized that men would benefit more from EWI’s than women due to societal norms that restrict emotional expression in men (Smyth Reference Smyth1998). Accordingly, EWIs could serve as a valuable outlet to promote emotional disclosure for men with cancer. Incorporating gender considerations into the design of health programs and studies strengthens the literature and improves patient outcomes (Griffith et al. Reference Griffith, Gunter and Allen2011), as such investigators and clinicians exploring EWIs for patients with cancer should be mindful of the influence of gender on biopsychosocial factors that may impact these interventions.
Additionally, there is a significant gap in racial and ethnic representation in the literature on EWIs and cancer, particularly concerning non-White or non-Asian patients. Despite most studies focusing on cancers in the USA, the represented patient populations do not reflect the diversity seen in clinical practice (Turner et al. Reference Turner, Steinberg and Weeks2022). Reassuringly, the current literature provides that when racial- and ethnic-specific studies are conducted, they yield insightful results. From the 12 studies that only included patients of Asian (Chinese) descent, insights regarding the impact of acculturation, language, Confucian and collectivist culture, stigma, and social constraints were provided. Utilizing these studies as models for research in historically underrepresented racial and ethnic groups may offer critical insights into best practices for implementing EWIs as adjunctive therapy in cancer treatment.
The synthesis of this review provides insights for investigators and clinicians considering integrating EWIs into cancer care. First, EWIs should be tailored to the cultural and individual needs of patients with cancer. For example, the qualitative data synthesized in this study suggest that patients who come from cultures with more collectivist values may resonate with the privacy and safety that EWIs provide (Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016; Wang et al. Reference Wang, Geng and Ji2020) and benefit from prompts structured around their cultural values and in their native language (Wang et al. Reference Wang, Geng and Ji2020). Second, EWIs should prioritize delivery formats that prioritize privacy and accessibility, such as online formats (e.g., MyCB and EYH) (Brkic et al. Reference Brkic, Prichard and Daly2024; Melissant et al. Reference Melissant, Jansen and Eerenstein2021; Mifsud et al. Reference Mifsud, Pehlivan and Fam2021; Przezdziecki et al. Reference Przezdziecki, Alcorso and Sherman2016; Sherman et al. Reference Sherman, Przezdziecki and Alcorso2018), especially for sensitive topics such as body image distress. Third, interventions should be timed strategically to prioritize emotional disclosure and maximize therapeutic benefits. Most studies indicating a positive impact on clinical outcomes for EWIs in patients with cancer involved interventions delivered after active treatment when patients may have had a greater capacity for reflection and engagement with the EWI. Fourth, future research must address inclusivity gaps by expanding EWI investigations to cancer predominantly affecting men, and clinicians should encourage their patients with cancer who are men to engage in emotional disclosure exercises, such as EWIs, given theoretical evidence suggesting its benefit for this population (Hoyt Reference Hoyt2009; Smyth Reference Smyth1998). Fifth, investigators must standardize outcome measures in studies assessing EWI’s impact on this patient population, to decrease heterogeneity. Although our synthesis identifies positive associations between EWIs and clinical outcomes, the heterogeneity present in recent studies limits the conclusions that can be made.
There were several limitations in this study that should be noted. First, the reviewed studies were impacted by patient-reported outcome biases, and heterogeneity in the protocol for EWIs, writing prompts, follow-up time, and outcome measures, highlighting the continued need for rigorous studies designed to maximize patient inclusivity, generalizability, and outcomes. Furthermore, although rigorous efforts were made to conduct the search strategy for the current scoping review, this study may not include all available literature on EWIs in patients with cancer. Lastly, by design, this study does not include meticulous meta-analysis or appraisal of the data presented by the studies in the review. As such, future studies may uncover insights and findings from the data in the studies of this review that were not elucidated by our study design. However, the purpose of this scoping review was to present a synthesis of the existing and developing body of literature regarding EWIs in patients with cancer and to identify gaps that may provide areas of improvement for future studies.
Conclusion and future recommendations
This scoping review synthesizes the quantitative and qualitative data from 28 studies (2015–2025) on EWIs’ potential benefits in cancer care. Our synthesis provides that EWIs are predominantly positively associated with clinical outcomes in patients with cancer, and qualitative insights provide that EWIs offer safe emotional disclosure through narrative reconstruction and culturally adaptive delivery. Studies lack gender, racial, and ethnic diversity, highlighting the need for investigations of EWIs in men and underrepresented minority patients (e.g., Black and Latino) with cancer. Culturally tailored interventions and privacy-focused online delivery demonstrate promise in addressing perceived and experienced stigma in this patient population. Timing EWIs post-treatment may optimize benefits, and future research must standardize EWI protocols to strengthen conclusions on the efficacy of integrating EWIs into cancer care.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/S1478951525100394.
Acknowledgments
We thank the Harvard Medical School of Scholarly Engagement. We acknowledge the invaluable contributions of patients, physicians, investigators, professors, and administrators involved in this study and all the studies reviewed in this study.
Funding
This research received no specific grant from any funding agency, commercial, or not-for-profit sectors.
Competing interests
The authors have no disclosures.
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