Does writing about their worst-case scenarios help advanced cancer patients better deal with the stress and anxiety they feel about their disease progression?
That’s what University of Colorado Cancer Center member Joanna Arch, PhD, aims to find out in an upcoming clinical trial funded by the National Cancer Institute (NCI).
“I have been doing interventions with cancer populations for over a dozen years, and I have become increasingly interested in developing more precise approaches to get at what is most troubling to them, particularly people with advanced cancer diagnoses,” says Arch, a professor in the Department of Psychology and Neuroscience at CU Boulder.
Writing it down
Several years ago, Arch, who is trained in written exposure therapy, an intervention for post-traumatic stress disorder, began looking at ways to adapt that therapy for people with advanced cancers who were plagued with worries about their future.
“Written exposure therapy involves writing yourself into wellness — you identify your most intense trauma, and you write about it in a very systematic way for five sessions,” she says. “I became interested in this notion that maybe I could adapt that to address core fears in advanced cancer.”
Unlike PTSD survivors, Arch says, most people with advanced or incurable cancer aren’t focused on past traumas; they are anticipating future loss and trauma such as saying goodbye to loved ones or being unable to care for themselves physically. She hypothesized that writing about those imagined worst-case future scenarios would help cancer patients better cope with them, and with a grant from the CU Cancer Center, she ran a pilot study in 2023 to test the theory.
“I wanted to find out if people could identify their imagined future worst-case scenario with cancer, and if we could adapt the written exposure protocol to help them process and move through that imagined scenario so that it's not constantly haunting them and preventing them from engaging with the precious life that remains,” she says.
Moving to a randomized trial
The NCI-funded, randomized trial will take the experiment a step further, randomizing patients either to standard supportive care or standard supportive care plus the written exposure intervention, which Arch calls EASE. She aims to launch recruitment in early 2026, and EASE will be offered in English and Spanish.
“We’re recruiting from CU, as well as community-based cancer clinics, and anybody with a stage IV solid tumor cancer diagnosis of any type is eligible, as are people with a glioblastoma, certain types of lung cancer, or recurrent stage three ovarian cancer,” she says. “The psychological criteria are that people need to have elevated fear of cancer progression and trauma symptoms related to their cancer, which include things like intrusive thoughts or images about cancer or strong reactivity to cancer-related cues.”
Confronting the worst case
Participants randomized to EASE will receive one session a week for five weeks, plus an intake session, delivered by video conferencing.
“Patients can be anywhere in the state, and they'll be working one-on-one with an interventionist who's trained in EASE,” Arch says. “In the intake session, the interventionist works with the participant to identify their worst-case scenario, because for some people, it's on the tip of their tongue, and for other people, they have to really sit and get in touch with what they're afraid of. We have found that spending more time on that process and not rushing people makes it more likely that we're actually hitting on their true worst-case scenario.”
In the first three sessions, participants write about their worst-case scenario for 30 minutes each session.
“It's not general thoughts and feelings about cancer they're writing about,” Arch says. “They are writing in a very specific and structured way about the worst-case scenario as an event with a beginning, middle, and end, and they're sharing their deepest thoughts and feelings about that event as it's unfolding in the writing.”
In sessions four and five, or the coping sessions, the interventionists talk with participants about what they’ve written and if writing about them has changed their perceived ability to cope with the scenarios.
In these two final sessions, “they write about how they could cope with that scenario and what they can do now and in the future to reduce its negative impacts on themselves and others,” Arch says. “If they think that the worst-case scenario isn't going to actually happen in the way they had imagined it, they write about what they think their better-case scenario is and what they can do to make that better-case scenario more likely, and what resources they can mobilize to support themselves and their loved ones.”
A better future
Based on the results of the pilot study, Arch hopes that the randomized trial will reveal that EASE — which is inexpensive to implement and easy to train interventionists in — will help advanced cancer patients better manage their fears about the future.
“By writing about it, they're moving through that fear, and they’re also reevaluating the fear and activating their own coping capacities,” says Arch, who is in the planning stages of an EASE trial for cancer caregivers. “That boosts their self-efficacy and their ability to see all the power that they do have, instead of focusing just on the power that they don't have.
“What we're hoping is that EASE improves people's quality of life, that it reduces their fear of progression and their cancer-related trauma symptoms, that it reduces anxiety, depression, and hopelessness, and that it improves engagement with their values and goals and their ability to cultivate compassion and kindness towards themselves, which hopefully will benefit their loved ones, too.”
