Effects of art therapy in cancer care: A systematic review and meta‐analysis

Are Art-Based Interventions Effective in Improving Psychological Well-Being Among Informal Caregivers of Cancer Patients? A Systematic Review

Objectives: To systematically synthesize the current evidence on the effects of art-based interventions on improving anxiety, depression, stress, sleep, and well-being of cancer caregivers. Design: A systematic review. Methods: We searched PubMed, EMBASE, Web of Science, CINAHL, PsycINFO, and Cochrane Central Register of Controlled Trials databases from their inception up to April 2024. Studies exploring the effects of art-based interventions on the psychological symptoms of cancer caregivers were included. We did not restrict the publication to the particular study designs, including randomized controlled trials, quasiexperimental studies, and qualitative studies. Results: Fifteen studies of 607 participants were identified in this systematic review. Overall, the existing studies provided preliminary evidence to suggest that art-based interventions may benefit cancer caregivers in improving anxiety, depression, stress, caregiver burden, and quality of life. However, the relatively low quality of the current evidence limits the efficacy of these findings. Conclusions: According to the existing evidence, the therapeutic benefits of using art-based interventions for improving the psychological well-being of cancer caregivers are uncertain. More high-quality and well-designed studies are still required to confirm the psychological effectiveness of art-based interventions for cancer caregivers in the future.

Effectiveness of creative arts therapy for adult patients with cancer: a systematic review and meta-analysis

OBJECTIVES

This systematic review and meta-analysis aimed to assess the effectiveness of creative arts therapy (CAT) interventions on the health outcomes of adult patients with cancer.

METHODS

A comprehensive search was conducted in six databases from their inception to June 10, 2023, with no restrictions on sex, age, cancer type, cancer stage, or treatment type. The Cochrane Risk of Bias (RoB2) tool for randomized controlled trials (RCTs) and the equivalent tool for non-RCTs (ROBINS-I) were used to assess the risk of bias. Meta-analyses were conducted to pool estimates of the effects of CAT on patients' health-related outcomes. A narrative synthesis of outcomes was performed where meta-analysis was not appropriate.

RESULTS

A total of 25 studies (8 RCTs and 17 quasi-RCTs) involving 1489 cancer patients and survivors were included in the final data analysis. Most studies focused on patients with mixed cancer diagnoses who were undergoing active chemotherapy treatment. Most studies utilized painting, drawing, and/or sculpting as CAT interventions. The overall risk of bias in the included studies was moderate to high. Meta-analysis demonstrated a significant improvement in quality of life (SMD with 95% CI = 17.50, 10.05-24.95, P =.0000) and the social aspect of quality of life in cancer patients (SMD with 95% CI = 03.1 (0.06-0.55), P = .01), but no significant effects were found for depressive symptoms and coping strategies among patients who participated in CAT compared to control groups. Narrative analysis and non-RCTs suggested the potential of CAT in reducing levels of depression and anxiety, as well as improving self-image, hope, emotional expression/state, and processing in patients with cancer. However, inconsistent findings were reported regarding the effectiveness of CAT interventions on fatigue, spirituality, and psychosomatic distress/symptom intensity.

CONCLUSION

The findings indicated significant and potential benefits of CAT for individuals with cancer, primarily related to quality of life. However, caution is needed in interpreting these findings due to limitations in the methodologies utilized in the included studies. Further large-scale RCTs are needed to examine the effectiveness of CAT on health outcomes, particularly in relation to self-image, hope, and emotional expression/state and processing among patients with cancer or those in palliative care.

Effects of Visual Art Therapy on Positive Symptoms, Negative Symptoms, and Emotions in Individuals with Schizophrenia: A Systematic Review and Meta-Analysis

Schizophrenia is characterized by psychiatric symptoms and emotional issues. While pharmacological treatments have limitations, non-pharmacological interventions are essential. Art therapy has the potential to enhance emotional expression, communication, and health; however, the effectiveness of visual art therapy remains uncertain. This systematic review and meta-analysis synthesizes the findings of randomized controlled trials (RCTs) of visual art therapy on positive symptoms, negative symptoms, and emotions in patients with schizophrenia. This study reviews RCTs published prior to February, 2024. The PubMed, Embase, Cochrane Library, CEPS, CNKI, Wanfang, and Yiigle databases were searched, and three independent researchers screened the studies. In this meta-analysis, standardized mean difference (SMD) was employed as a measure to calculate effect sizes for continuous variables using a random effects model, while the meta-regression and subgroup analyses were performed with patient and intervention characteristics. A total of 31 studies revealed visual art therapy had a significant small-to-moderate effect on positive symptoms (SMD = 0.407, 95% CI 0.233 to 0.581), a moderate effect on negative symptoms (SMD = 0.697, 95% CI 0.514 to 0.880), a moderate effect on depression (SMD = 0.610, 95% CI 0.398 to 0.821), and a large effect on anxiety (SMD = 0.909, 95% CI 0.386 to 1.433). The subgroup analysis revealed painting and handcrafts had significant effects on positive symptoms, negative symptoms, and emotions. Combined Chinese calligraphy and painting had significant effects on positive symptoms, depression, and anxiety. Better improvement was noted among the Asian population, and a longer weekly treatment duration was associated with better improvement in positive symptoms. Female participants tended to have more improvements in negative symptoms and anxiety through visual art therapy. The results indicate that visual art therapy has positive effects on the psychiatric symptoms and emotions of individuals with schizophrenia. We recommend future research further investigate art therapy modalities and durations.

Effects of psychotherapy interventions on anxiety and depression in patients with gastrointestinal cancer: A systematic review and network meta-analysis

OBJECTIVE

Various psychological interventions have been demonstrated to be effective at preventing anxiety and depression symptoms in patients with gastrointestinal (GI) cancer. However, it remains unclear which intervention is the best option. This study aimed to evaluate the impact of various psychological interventions on anxiety and depression in symptomatic patients with GI cancer.

METHODS

The PubMed, Cochrane Library, Embase, CNKI, WanFang Data, and VIP databases were systematically searched from inception to June 2023 to identify randomized controlled trials (RCTs). The primary outcomes were anxiety and depression levels. Two reviewers independently selected the studies, extracted the data based on prespecified criteria, and evaluated the risk of bias using the Cochrane Collaboration risk of bias tool. Stata 14.0 was used to conduct network meta-analysis.

RESULTS

Thirty-two RCTs (2453 patients) involving 9 psychological interventions were included. The results of the network meta-analysis showed that cognitive-behavioral therapy (CBT; mean difference [MD] = -4.98, 95% CI (-7.04, -2.93), relaxation therapy (MD = -4.39, 95% CI (-7.90, -0.88), reminiscence therapy (MD = -5.01, 95% CI (-8.20, -1.81)), and narrative nursing (MD = -4.89, 95% CI (-8.54, -1.23)) significantly reduced anxiety levels, and CBT (MD = -2.15, 95% CI (-4.28, -0.02), reminiscence therapy (MD = -7.20, 95% CI (-10.48, -3.91), and narrative nursing (MD = -7.20, 95% CI (-10.48, -3.91)) significantly reduced depression levels in patients with GI cancer compared with conventional nursing care.

CONCLUSION

The findings of this network meta-analysis revealed that CBT, reminiscence therapy and narrative nursing can be actively considered as part of sequential therapy to reduce anxiety and depression levels in patients with GI cancer.

The effects of art-making intervention on mind-body and quality of life in adults with cancer: a systematic review and meta-analysis

PURPOSE

To investigate the effectiveness of art-making interventions on physical and psychological outcomes, as well as quality of life (QOL), in adult patients with cancer.

METHODS

Seven English-language databases (PubMed, Academic Search Premier, EMBASE, CINAHL, PsycINFO, The Cochrane Library, and Web of Science) and three Chinese-language databases (CNKI, WanFang, and VIP) were searched up to and including May 1, 2023. We used the Cochrane Risk of Bias tool 2.0 and the Risk of Bias in Non-Randomized Studies-of Interventions to evaluate the certainty of evidence. The data were analyzed using Review Manager software 5.4. The study protocol was registered with PROSPERO (CRD42022321471).

RESULTS

The studies predominantly focused on visual art (n = 21), two specifically used performing art (n = 2), and five integrated both forms of art-making (n = 5). The pooled results showed that art-making significantly improved anxiety (SMD =  - 1.12, 95% CI [- 1.43, - 0.81], p < 0.01), depression (SMD =  - 0.91, 95% CI [- 1.16, - 0.65], p < 0.01), distress (SMD =  - 1.19, 95% CI [- 1.43, - 0.95], p < 0.01), psychological well-being (SMD = 0.41, 95% CI [0.02, 0.80], p = 0.04), societal well-being (SMD = 0.29, 95% CI [0.04, 0.54], p = 0.03), nausea (SMD =  - 1.81, 95% CI [- 2.84, - 0.78], p < 0.01), physical well-being (SMD = 0.11, 95% CI [0.02, 0.20], p = 0.02), and QOL (SMD = 0.81, 95% CI [0.29, 1.33], p < 0.01). However, it did not significantly improve fatigue (SMD =  - 0.28, 95% CI [- 0.75, 0.19], p = 0.24) and pain (SMD =  - 0.18, 95% CI [- 1.97, 1.60], p = 0.84) in patients with cancer.

CONCLUSIONS

Art-making interventions may boost psychological well-being, physical symptoms, and QOL among patients with cancer. More robust studies are necessary to overcome methodological limitations and promote wider adoption of these interventions.

TRIAL REGISTRATION

Prospero registration number: CRD42022321471.

Life meaning constructed from dignity therapy in traditional Chinese culture: A qualitative analysis of dignity therapy generativity documents

OBJECTIVES

To examine the thematic features of dignity therapy generativity documents of advanced cancer patients receiving chemotherapy in mainland China from the perspective of meaning-making during dignity therapy.

METHODS

This is a qualitative descriptive study. Content analysis was used to analyze 24 dignity therapy generativity documents derived from a quasi-experimental trial of dignity therapy for advanced cancer patients receiving chemotherapy in a daycare center at a cancer hospital in northern China.

RESULTS

Among the 24 advanced cancer patients whose generativity documents were analyzed, 14 were male and ranged in age from 26 to 78 years (average = 50.3). Two dimensions emerged from the data: (1) the sources of meaning in life, which consisted of social relationships, things and circumstances providing meaning in life, and (2) the ultimate meaning in life, referring to finding one's real self and realizing the purpose in life, including personal life goals, dignity and autonomy, and morality of patients.

SIGNIFICANCE OF RESULTS

The multidimensional constructs of meaning in life with distinctive traditional Chinese cultural characteristics could provide insights into dignity-conserving care for advanced cancer patients with Chinese culture and provide evidence for refining the implementation protocol of DT through intentionally addressing the ultimate meaning of patients in the therapeutic session.

Effects of Music Therapy on Spiritual Well-Being among Patients with Advanced Cancer in Palliative Care: A Meta-Analysis of Randomized Controlled Trials

PURPOSE

Patients with advanced cancer in palliative care often experience physical and psychological symptoms that negatively impact their quality of life (QoL) and spiritual well-being. Music therapy can be used for symptom management in these patients. However, the effectiveness is uncertain. To determine the effectiveness of music therapy on spiritual well-being, QoL, pain, and psychological distress using randomized controlled trials (RCTs).

DATA SOURCE

A systematic search was conducted in EMBASE, PubMed, Cochrane Library, CINAHL, Web of Science, and the ClinicalTrial.gov registry up to September 2022.

CONCLUSION

The meta-analysis included seven RCTs with a total of 747 advanced cancer patients. Music therapy was found to significantly improve spiritual well-being with a mean difference of 0.43 (95% CI: 0.25 to 0.61, P < .001) in the intervention group compared to the control group. However, no significant group differences were found between the intervention and control groups for QoL (SMD: 0.53, 95% CI: -0.12 to 1.13, P = .11), pain (MD: -0.81, 95% CI: -2.06 to 0.44, P = .20), and psychological distress (SMD: -0.05, 95% CI: -0.41 to 0.32, P = .81). Music therapy can effectively improve the spiritual well-being of palliative care patients. However, its beneficial effects on QoL, pain, and psychological distress were minimal.

IMPLICATIONS FOR NURSING PRACTICE

Music therapy interventions can be introduced to help patients deal with spiritual/existential needs. Future studies should identify optimal characteristics of music therapy interventions to aid in enhancing the quality of palliative care for patients with advanced cancer.

The role of arts engagement in reducing cognitive decline and improving quality of life in healthy older people: a systematic review

In recent years, arts engagement has been proposed as a non-pharmacological approach to reduce cognitive decline and increase well-being and quality of life in specific populations such as the elderly or patients with severe disease. The aim of this systematic review was to assess the effects of receptive or active arts engagement on reducing cognitive decline and improving quality of life and well-being in healthy populations, with a particular focus on the role of arts engagement in the long term. A comprehensive search strategy was conducted across four databases from February to March 2023. Ten studies with a total of 7,874 participants were incorporated in accordance with the PRISMA guidelines. Active and receptive arts engagement was found to be an effective approach to reduce cognitive decline and improve well-being and quality of life in healthy populations. The role of the positive effects of arts engagement could be determined by the combination of several factors such as exposure to cultural activities and the group effect. There is limited evidence of the protective effects of active arts engagement over a long period of time. Given the increasing demand for preventive programmes to reduce the negative effects of population ageing, more research on arts engagement should be conducted to identify its mechanisms and long-term effects.

Integrating mindfulness and the expressive arts for meaning making in cancer care: A grounded theory of the processes, facilitators, and challenges

PURPOSE

There is a growing interest in mindfulness-based expressive arts interventions in oncology, to help patients process their experiences, learn how to live with cancer, and ameliorate psychological distress. Our research purpose was to explore how patients with cancer experience a mindfulness-based expressive arts group intervention, and to articulate individual and contextual factors influencing their experiences.

METHODS

We conducted a constructivist grounded theory study and recruited 32 participants who experienced a 10-week mindfulness-based expressive arts group intervention at a tertiary cancer center in mid-Western Canada. We gathered socio-demographic data and descriptions of their experiences through semi-structured interviews. Participants brought art they had created to facilitate art elicitation. Socio-demographic data were analyzed with descriptive statistics and all other data with grounded theory methods.

RESULTS

Our findings revealed how entering the group and meaning making processes through mindfulness enabled participants to let go of their ruminations and calm their minds so they could fully engage in arts activities. Participants found inspiration for their artistic expressions in mindfulness meditation which allowed them to express themselves in new ways. Although this work was challenging, combining mindfulness and the arts created a unique healing space in which individual work was nested within group processes. There were notable personal factors and perspectives that influenced participants' experiences, as well as factors related to the group design and facilitator.

CONCLUSIONS

Our findings provide insight into how and when this intervention was meaningful for patients, and have important implications to guide ongoing intervention development, implementation, and evaluation.

Online art therapy pilot in the Western Isles of Scotland: a feasibility and acceptability study of a novel service in a rural community

Introduction

Art therapy, despite being an evidence-based, safe and acceptable intervention, is not widely available to clients in Scotland. Online delivery has the potential to expand the reach and accessibility, but special considerations need to be given to designing successful online art therapy services, due to the unique emphasis on the role of an image and artmaking alongside the therapeutic relationship.

Methods

A pilot online art therapy service was developed and delivered in the Western Isles of Scotland to individual adult clients wishing to increase their psychological wellbeing. This research aimed to assess feasibility and acceptability of the novel service, identify enablers and challenges in setting up and delivering the service, explore participants' expectations and experiences of art therapy and identify any impacts of the service. Mixed-method evaluation incorporated questionnaires, focus groups, interviews and Audio Image Recordings (AIRs). Findings were grouped into themes across several key areas: service setup, research procedures, intervention design and impacts and insights. Recommendations were developed for the first three areas and the last section presents indications of change and gives voice to client experience primarily.

Results

Online art therapy was described by clients as a judgement-free zone which allowed freedom to experiment, express, feel and immerse themselves in the creative flow. Other benefits included readiness to accept emotions, increased understanding of self and others and being able to see things from a new perspective. Clients recognised the unique nature of art therapy in relation to other psychological treatments and valued the freedom of expression it offered, including the non-verbal.

Discussion

This project demonstrated that online art therapy is not only a feasible an acceptable intervention, but potentially also a powerfully impactful one, capable of instilling a positive change in a surprisingly short period of time. Exploring ways to expand current and introduce new art therapy services is highly recommended. Refinement of an intervention design, tools and research procedures is recommended through further feasibility studies of a larger scale.

Art-based interventions for women's mental health in pregnancy and postpartum: A meta-analysis of randomised controlled trials

Objective

Pregnant and postpartum women are vulnerable to psychological problems with a high estimated prevalence. To date, there is no meta-analysis that specifically assesses the effectiveness of art-based interventions to improve mental health in pregnant and postpartum women. The objective of this meta-analysis was to assess the efficacy of art-based interventions when delivered to pregnant and postpartum women.

Methods

Systematic literature searches were conducted from the inception to 6 March 2022 in seven English databases, including PubMed, Embase, Cochrane Central Register, CINAHL, ProQuest, Scopus, and Web of Science. Randomised controlled trials (RCTs) reporting art-based interventions targeting the improvement of women's mental health in pregnancy and postpartum were included. Cochrane risk of bias tool was applied to assess evidence quality.

Results

Twenty-one randomised controlled trials (RCTs) involving 2,815 participants were eligible for data analysis. A pooled analysis demonstrated that art-based interventions significantly reduced anxiety (SMD = -0.75, 95% CI = -1.10 to -0.40) and depression symptoms (MD = -0.79, 95% CI = -1.30 to -0.28). However, art-based interventions did not alleviate stress symptoms as expected in our findings. Subgroup analysis demonstrated that intervention implementation time, intervention duration and music selected by the participants vs. not could have influence on the efficacy of art-based intervention for anxiety.

Conclusion

In perinatal mental health, art-based interventions may be effective in alleviating anxiety and depression. In the future, we still need to conduct high-quality RCTs to validate our findings and enrich clinical application of art-based interventions.

Reducing anxiety and improving self-acceptance in children and adolescents with osteosarcoma through group drawing art therapy

Purpose

This study explored the effect of group drawing art therapy (GDAT) on anxiety and self-acceptance in children and adolescents with osteosarcoma.

Methods

Using a randomized experimental study design, 40 children and adolescents with osteosarcoma who were treated in our hospital from December 2021 to December 2022 were selected as the research objects, including 20 in the intervention group and 20 in the control group. The control group received routine care for osteosarcoma, while the intervention group participated in eight sessions of GDAT, twice a week, 90-100 min each, in addition to routine care for osteosarcoma. A screening for children's anxiety disorders (SCARED) and a self-acceptance questionnaire (SAQ) were used to evaluate the patients before and after the intervention.

Results

After 8 weeks of GDAT, the SCARED total score in the intervention group was 11.30 ± 8.603, and that in the control group was 22.10 ± 11.534. The difference between the two groups was statistically significant (t = -3.357, P < 0.05). In the intervention group, the SAQ total score was 48.25 ± 4.204, with self-acceptance and self-evaluation factor scores of 24.40 ± 2.521 and 23.85 ± 2.434, respectively. In the control group, the SAQ total score was 42.20 ± 4.047; the self-acceptance factor score was 21.20 ± 3.350 and that of the self-evaluation factor was 21.00 ± 2.224. The differences between the two groups were statistically significant (t = 4.637, P < 0.001; t = 3.413, P < 0.05; t = 3.866, P < 0.001, respectively).

Conclusion

Group drawing art therapy can reduce anxiety and improve the levels of self-acceptance and self-evaluation in children and adolescents with osteosarcoma.

The therapeutic potential of bedside art observation in hematologic cancer inpatients: a randomized controlled pilot study

PURPOSE

Prior research has suggested that art-based interventions may reduce anxiety in cancer patients and enhance dialogue in the healthcare setting. Through implementing Art at the Bedside, an art-based hospital visitation program, we sought to examine whether dedicated art observation sessions, and varying formats (with and without guided discussion), could have therapeutic effects on cancer patients' mental wellbeing.

METHODS

This randomized controlled pilot study evaluated the effects of bedside art observation on anxiety in a sample of 73 hematologic cancer inpatients. We compared state anxiety, as measured by an abbreviated form of the Spielberger State-Trait Anxiety Inventory (STAI Y-6), across three groups (participants who observed an electronic selection of artwork with and without guided discussion, and a control group that did not engage in either dedicated art observation activity).

RESULTS

We found that mean anxiety scores were significantly lower among those who participated in guided art observation, compared to those who did not (8.92 versus 12.1, scored on a scale of 6 to 24, p = 0.009, with a medium effect size (η² = 12.7)). The majority of participants who engaged in art observation felt that the activity provided positive distraction (85.7%) and decreased boredom (79.6%), and many noted that it reduced feelings of anxiety (46.9%) and depression (24.5%).

CONCLUSION

These findings suggest that bedside art observation, particularly with guided discussion, may be a promising complementary therapy for reducing cancer-related anxiety and improving the patient experience in the inpatient hematology/oncology setting, and would benefit from further inquiry.

Experiences of Turkish Parents of Hospitalized Children With Cancer During the COVID-19 Pandemic: A Qualitative Study

PURPOSE

To describe the experiences of Turkish parents of hospitalized children with cancer during the COVID-19 pandemic.

PARTICIPANTS & SETTING

Participants were recruited at the pediatric hematology-oncology clinic of a university hospital in Turkey. A purposive sampling strategy was used to identify participants. Parents who had a child aged 0-18 years with cancer were eligible.

METHODOLOGIC APPROACH

This study was conducted using a descriptive qualitative research design. Semistructured individual interviews with 14 parents of children with cancer were used for data collection. Data were analyzed using the content analysis method.

FINDINGS

Two main themes with related subthemes were identified that revealed the lived experiences of parents of children with cancer.

IMPLICATIONS FOR NURSING

Pediatric oncology nurses can develop clinical practices that help parents to cope with anxiety about COVID-19. Nurses should share with parents current and valid information about the child's care during the pandemic. Future research should examine the experiences of children with cancer and their parents from different cultures during the COVID-19 pandemic.

The effectiveness of mandala drawing in reducing psychological symptoms, anxiety and depression in hospitalised adolescents with cancer: A randomised controlled trial

OBJECTIVE

This study aimed to evaluate the effectiveness of individual mandala drawing methods on psychological symptoms, anxiety and depression in hospitalised adolescents with cancer.

METHODS

A randomised controlled trial design with repeated measures was conducted. The study was carried out in a paediatric haematology and oncology clinic in Turkey. The study protocol is registered at ClinicalTrials.gov NCT04297982. The study sample consisted of 60 hospitalised adolescents aged between 12 and 17. Participants were randomly assigned to receive two 1- to 2-h mandala drawing sessions (intervention group, n = 30) or routine care only (control group, n = 30). Each adolescent was assessed using the Hospital Anxiety and Depression Scale and the Memorial Symptom Assessment Scale (Psychological subscale) questionnaires and was evaluated at baseline and after 5 days.

RESULTS

The anxiety and depression scores significantly decreased in the intervention group, compared with the control group, after 5 days of intervention, F(1, 57) = 28.9, p < 0.01, η²  = 0.337. Similarly, the psychological symptoms scores significantly decreased in the intervention group, compared with the control group, F(1, 57) = 69.7, p < 0.001, η²  = 0.550).

CONCLUSION

The individual mandala activity intervention was effective in reducing on psychological symptoms, anxiety and depressive symptoms in adolescents with cancer.

Current Status of Complementary Therapies Provided by Hospice Palliative Care in South Korea

Purpose

The aim of this study was to investigatecomplementary therapiesprovided at hospice palliative care facilities in South Koreaas designated by the Ministry of Health and Welfare.

Methods

The survey was conducted via e-mail from September 2 to September 23, 2020, with responsesfrom 109 therapists and 59 managers from 55 different hospice care facilities.

Results

Hospices provided an average of 3.67 different types of therapies, ranging from 1 to 7 different types. The most common types of therapies were horticultural therapy (81.4%), music therapy (79.7%), art therapy (76.3%), and aromatherapy (57.6%). The average frequency of sessions was once a week, the median duration was 60 minutes. Most therapists (96.3%) had qualifications, but the certification-issuing organizations and training intensiveness varied greatly. None of the therapists were employed on a full-time basis, and their average monthly income was KRW 270,000. Therapists and managers gave average scores of 8.90 and 8.38 out of 10, respectively, regarding the positive impact of complementary therapies on patients.

Conclusion

In order for patients and their families to benefit from complementary therapiesat hospice care facilities, in addition tobetter terms of employment for therapists, evidence-based guidelines for different types of therapies are needed so that therapy sessions can be conducted according to the theoretical underpinnings and characteristics of the type of therapy. It is expected that the results of this study will be used for policy-making in support of therapy as an essential hospice service.

Protocol for the REPAT study: role of emotional processing in art therapy for breast cancer palliative care patients

INTRODUCTION

Patients with breast cancer (BC) cope with depression which is linked to functional limitations in survivorship and to physical symptoms. Pain and fatigue are prominent symptoms that affect the well-being of cancer survivors. Emotional processing has been associated with improved physical and psychological health in survivors. Art therapy is a form of psychotherapy that involves the use of visual art-making for expression and communication. It encourages emotional processing and has been linked to symptom reduction in patients with cancer. This protocol is designed to examine two mechanistic changes: emotional processing (awareness, expression and acceptance) and cholinergic anti-inflammatory processes (heart rate variability and cytokine expression) through which an art therapy intervention may reduce depression, pain and fatigue. In addition, we will examine ethnocultural differences in the effect of art therapy in women from different ethnocultural backgrounds.

METHODS AND ANALYSIS

A randomised controlled study with careful controls will randomise 240 patient with BC (50% Jewish and 50% Arab) to an 8-week group art therapy intervention or an 8-week Mandala colouring comparison group. This design will test the mechanisms of art therapy on the targeted outcomes beyond the effects of time with a group, focus on a task and engagement with art materials. We will examine two potential mechanisms: emotional processing and cholinergic anti-inflammatory processes; of the intervention effects on depression, pain and fatigue and compare these effects in Arab versus Jewish women.

ETHICS AND DISSEMINATION

Participants will sign informed consent before participation and will be informed that they can leave the study at any point in time without effect on their medical treatment. The Helsinki committees of each participating hospital have approved the study. Data collected in this study will be published in peer-review journals, and we will use the platform of the study website (http://repat.haifa.ac.il/en/) for further dissemination to the general public.

TRIAL REGISTRATION NUMBER

The study is registered in ClinicalTrials.gov: NCT03377816; Pre-results.