Background: Despite art therapy has been widely used in cancer population to improve their physical and mental health, painting therapy, as one form of art therapy, is seldom applied to adult cancer patients independently. Therefore, how painting therapy affects adult cancer patients’ health outcomes needed to be explored sufficiently. Objectives: The purpose of this review was to assess and synthesize the latest evidence of painting therapy concerning adult cancer patients, and to provide some inspiration for clinical staff. Methods: A literature research of PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL, PsychoInfo, Psydex, CENTRAL, Google Scholar, British Library, CNKI, Wanfang, CQVIP electronic databases were undertaken with the following key words: art therapy, painting, drawing, cancer, neoplasm, tumor, carcinoma and oncology. A narrative synthesis was used according to PRISMA and the quality of study was assessed using acritical assessment tool. Results: Eleven papers reporting nine different research projects met the inclusion criteria. Generally speaking, painting therapy positively affected health outcomes. The impacts on patients include improvements in quality of life, coping with disease, mental health and somatic symptoms. However, inconsistency still exists. Three studies failed to show positive effects of painting therapy on post-traumatic growth, distress and coping behavior in participants. Conclusion: Robust evidence was found in rehabilitation of patients with various types of cancer. Painting therapy evidently affected cancer patients in a positive direction. However, the application of painting therapy to cancer patients needs to be explored further due to few studies on this topic.
It is an ongoing challenge to find novel ways to increase cancer awareness and provide support to cancer population. Up to now, complementary and alternative medicine (CAM) in relation to cancer treatment has been widely used. As one of various kinds of CAM, art therapy intended to improve the quality of life of patients. Art materials are used in art therapy for empowering individuals through the self-expression, self-identification and personal conflicts resolution in the presence of a trained art therapist [
Painting therapy is a form of art therapy mediated by painting activities. In 1986, Judy et al. developed a program “We can weekend” to help families to cope with cancer in a form of drawing and painting [
By summarizing the direction of evidence (positive, uncertain, negative), this review aimed to evaluate whether painting therapy could contribute meaningful impacts on cancer patients, and to explore how painting therapy work. The specific aims of this review include:
1) To synthesize the effect of painting art therapy on health outcomes of adult patients with cancer;
2) To explore the mechanism of painting therapy;
3) To identify the limitations of implemented painting therapy.
The review procedure was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
Search terms used were: (“tumor” OR “neoplasm” OR “cancer” OR “carcinoma” OR “oncology”) for cancer and (“drawing” OR “painting” OR “art”) for painting therapy. Search terms were a combination of MeSH terms and free-text terms. Relevant studies in English or Chinese were reviewed.
Inclusion criteria were:
1) Empirical studies with any type of design;
2) Outcomes including quality of life, coping with disease, mental health and somatic symptoms measured;
3) Cancer population aged 18 years or older;
4) Implementing painting therapy intervention;
5) Published in English or Chinese.
Exclusion criteria were:
1) Besides painting therapy, other forms of art therapy involved in the intervention;
2) Lack of full-text literature.
For included studies, the heterogeneity made it inappropriate to use Cochrane Collaboration approach. In order to assess the quality of a diverse group of empirical studies, Hawker developed an appraisal tool to evaluate studies using both qualitative methods and quantitative methods [
All retrieved articles were double-blind assessed to evaluate suitability for inclusion by two reviewers. Uncertainty was resolved by discussion with the third researcher. Data from the selected articles was extracted: Authors, year of publication, country, participants, study design, age range, intervention outcome measures and methodological issues.
As Eysenck stated, “Meta-analysis is only properly applicable if the data summarized are homogeneous―that is, treatment, patients, and end points must be similar or at least comparable” [
A total of 2077 titles and abstracts were screened, and 319 duplicates were identified. Of the 1758, 1642 were excluded via reviewing titles and abstracts. After reading the remaining 116 full-text articles, 106 articles were excluded because intervention in these studies did not meet the inclusion criteria and articles were not written in English or Chinese. One more study was identified by searching the reference lists. Finally, 11 papers were included [
Study characteristics were summarized in
Author Country | Design setting | Participants | Age (years) | Task | Course instructor | Assessment points | Outcomes and instruments | Results |
---|---|---|---|---|---|---|---|---|
Hammer et al. [ | Qualitative study Setting: gynecologic department of hospital | Patients with gynecologic cancer N = 15 | Range: 24 - 87 Median: m = 52 | One session after interviewing | Not mentioned | Hope | All participants experienced hope | |
Bar-Sela et al. [ | A non-randomized controlled trial Setting: oncology department of the hospital | Cancer patients on chemotherapy N = 60 N1 = 19 (intervention group, patients who participated with equal or more than 4 sessions) N2 = 41 (control group, patients who participated with equal or less than 2 sessions) | Range: 25 - 72 Median: m1 = 55 m2 = 55 | An weekly painting therapy, without mention of total sessions | More than one art therapist | before each session | 1) HADS measuring depression and anxiety 2) BFI measuring fatigue | Improvements of depression (P = 0.021) and fatigue (P = 0.24) in the intervention group |
Bozcuk et al. [ | A non-randomized controlled trial Setting: outpatient chemotherapy unit and home | Cancer patients undergoing chemotherapy N = 72 N1 = 48 (intervention group) N2 = 24 (control group) | Range: 22 - 73 Mean: M = 50.6 | A 12-week course. The first 6 weeks were to get known the details of this study, and the next 6 weeks were offered painting therapy | An experienced art therapist | t1: before intervention t2: after completing the intervention | 1) EORTC QLQ-C30 measuring QOL 2) HADS measuring anxiety and depression | Significant improvements of QOL (P = 0.001) and depression (P = 0.001) in the intervention group |
Geue et al. [ | A non-randomized controlled trial Setting: psychosocial counseling center in hospital | Patients with haematological malignancies N = 183 N1 = 54 (intervention group) N2 = 129 (control group) | Range: ≥18 Mean: M1 = 51.50 M2 = 53.45 | 22 weekly 90-min sessions | An artist receiving psycho- oncological training and evaluation | t1: before intervention t2: upon completing intervention t3: 6 months after t2 | 1) FQCI measuring coping with illness 2) PACIS measuring coping with illness 3) HADS measuring distress | No effect on participants’ psychological distress and coping behavior |
Geue et al. [ | A non-randomized controlled trial Setting: psychosocial counseling center in hospital | Cancer patients N = 53 N1 = 22 (less distressed) N2 = 31 (highly distressed) | Range: ≥18 Mean: M1 = 50 M2 = 53 | 22 weekly 90-min sessions | An artist receiving psycho- oncological training | t1: before intervention t2: after completing the intervention t3: 6-months after t2 | EORTC QLQ-C30 measuring QOL | No effect on QOL on participants but improvements of role, emotional and social functioning and fatigue in the group of highly distressed patients |
Oster et al. [ | A randomized controlled trial Setting: oncology department of the hospital | Women with non-metastatic breast cancer N = 41 N1 = 20 (intervention group) N2 = 21 (control group) | Range: 37 - 69 Median: m1 = 59.5 m2 = 55 | 5 weekly sessions after postoperative radiotherapy | Two trained art therapists | t1: before the start of radiotherapy t2: 2 months after radiotherapy t3: 6 months after radiotherapy | CRI measuring coping resources | An overall increase of coping resources in the intervention group |
---|---|---|---|---|---|---|---|---|
Singer et al. [ | A non-randomized controlled trial Setting: an outpatient psycho-oncology unit | Patients with haematological malignancies N = 165 N1 = 36 (intervention group) N2 = 129 (control group) | Range: ≥18 | 22 weekly 90-min sessions | An artist receiving psychological training and evaluation | t1: before intervention t2: immediately after intervention | SRGS measuring post-traumatic growth | No difference in post-traumatic growth between groups |
Peng et al. [ | A non-randomized controlled trial Setting: inpatient ward of the hospital | Patients with breast cancer undergoing chemotherapy N = 200 | Range: ≥18 Mean: M = 45.35 | Painting during the day of the second chemotherapy lasted for 2 - 4 h | The researchers themselves | t1: 24 h after first chemotherapy t2: 24 h after painting therapy | 1) FLIE measuring life function 2) SAS measuring anxiety | Significant improvements of life function (P < 0.001) and anxiety (P < 0.001) in the intervention group |
Svensk et al. [ | A randomized controlled trial Setting: oncology department of the hospital | Women with non-metastatic breast cancer N = 41 N1 = 20 (intervention group) N2 = 21 (control group) | Range: 37 - 69 Median: m1 = 59.5 m2 = 55 | 5 weekly sessions after postoperative radiotherapy | Two trained art therapists | t1: before the start of radiotherapy t2: 2 months after radiotherapy t3: 6 months after radiotherapy | 1) WHOQOL-BREF measuring QOL 2) QLQ-BR23 measuring QOL | An overall improvement of QOL in the intervention group |
Thyme et al. [ | A randomized controlled trial Setting: oncology department of the hospital | Women with nonmetastatic breast cancer N = 42 N1 = 20 (intervention group) N2 = 22 (control group) | Range: 37 - 69 Median: m1 = 59.50 m2 = 55 | 5 weekly sessions given after postoperative radiotherapy | Two trained art therapists | t1: before intervention, t2: following intervention t3: a 4-month follow-up | 1) SASB measuring self-image 2) SCL-90 measuring psychiatric symptoms | Significant improvements of psychiatric symptoms (P < 0.05) but no significant change on self-image in the intervention group |
Zhao & Tang [ | A randomized controlled trial Setting: demonstration classroom of the inpatient ward | Cancer patients N = 86 N1 = 43 (mandala drawing therapy) N2 = 43 (routine nursing care) | Mean: M1 = 53.3 M2 = 54.3 | 2 times per week for 6 weeks, 45 minutes each time | Members receiving training and evaluation of mandala painting psychotherapy | t1: before intervention t2: 2 weeks after intervention t3: 4 weeks after intervention t4: 6 weeks after intervention | SAS measuring anxiety | Significant improvement of anxiety (P < 0.05) in the intervention group |
Abbreviation: EORTC QLQ-C30: European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire; HADS: Hospital Anxiety and Depression Scale. FLIE: Functional Living Index―Emesis; SAS: Self-Rating Anxiety Scale; SRGS: Stress-Related Growth Scale; FQCI: Freiburg Questionnaire on Coping with Illness; PACIS: Perceived Adjustment to Chronic Illness Scale; SASB: The Structural Analysis of Social Behavior; SCL-90: The Symptom Check List-90; WHOQOL-BREF: The World Health Organization Quality of Life Instruments; EORTC QLQ-BR23: The European Organization for Research and Treatment of Cancer (EORTC) Breast-Cancer-Specific Quality of Life Questionnaire; BFI: The Brief Fatigue Inventory; CRI: The Coping Resources Inventory; QOL: Quality of Life; N: The Number of Participants; M: Mean Age; m: Median Age; t: Assessment Points.
The types of cancer included breast cancer, hematological tumor, multiple myeloma, Non-Hodgkin lymphoma, acute leukaemia, chronic leukaemia, Hodgkin lymphoma, gynecologic cancer, esophageal cancer and lung cancer. A total of 913 participants consisted of 630 women and 283 men at different stage of cancer were included.
In terms of study quality, the scores for quality evaluation ranged from 230 - 350 (see
All included studies reported setting. These studies occurred in psycho-social counselling center (N = 2), outpatient unit (N = 2) and inpatient unit (N = 7). Besidesasking patients to draw during chemotherapy administration, the study of Bozcuk also provided patients painting materials for home study at their convenience [
There was considerable heterogeneity regarding content, format of the painting therapy interventions. Frequency of intervention varied from 1 single session to 22 weekly sessions. Length of each session varied from 45 minutes to 4 hours, however, 7 studies just reported the number of sessions without reporting course duration (see
Author | Abstract and title | Introduction and aims | Method and data | Sampling | Data analysis | Ethics and bias | Results | Transferability or generalizability | Implications and usefulness | Total |
---|---|---|---|---|---|---|---|---|---|---|
Hammer et al. [ | 40 | 40 | 30 | 40 | 40 | 40 | 40 | 40 | 40 | 350 |
Bar-Sela et al. [ | 40 | 40 | 30 | 40 | 40 | 40 | 40 | 40 | 40 | 350 |
Bozcuk et al. [ | 40 | 30 | 30 | 30 | 40 | 10 | 40 | 30 | 40 | 290 |
Geue et al. [ | 30 | 40 | 40 | 40 | 30 | 40 | 40 | 40 | 30 | 330 |
Geue et al. [ | 40 | 40 | 40 | 30 | 40 | 20 | 40 | 40 | 40 | 330 |
Oster et al. [ | 30 | 40 | 30 | 40 | 40 | 30 | 40 | 40 | 40 | 330 |
Singer et al. [ | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 40 | 30 | 350 |
Peng et al. [ | 40 | 20 | 40 | 30 | 40 | 30 | 40 | 40 | 30 | 310 |
Svensk et al. [ | 40 | 30 | 30 | 40 | 30 | 40 | 40 | 40 | 40 | 330 |
Thyme et al. [ | 40 | 30 | 30 | 40 | 30 | 40 | 40 | 40 | 40 | 330 |
Zhao & Tang [ | 30 | 30 | 30 | 30 | 20 | 10 | 30 | 30 | 20 | 230 |
The included studies reported phased tasks with aims and methods during painting therapy. In Geue’s study [
A participant in painting therapy need not know any knowledge of painting. Participants’ works were finished in three ways: painting freely, painting according to specific theme and coloring picture. In four studies [
Most of the included studies have involved one or more art therapists except studies of Peng [
Quality of life, coping with disease (post-traumatic growth, coping with illness, self-image), mental health (anxiety, depression and hope) and somatic symptoms (life function, fatigue) were reported in the included studies. Positive effects of painting therapy on health outcomes were reported in 9 studies [
Three studies reported quality of life as an outcome (
Four studies reported coping with illness as an outcome (
Six studies reported mental health as an outcome (
Two studies reported somatic symptom as an outcome (
Strong evidence of positive effects of painting therapy on cancer patients’ quality of life, coping with disease, mental health and somatic symptom were detected. Although some inconsistencies still exist, there is no evidence that painting therapy causes harm.
The reasons why painting therapy influences cancer patients’ health have been presented in the included studies in this review. Here are some tentative interpretations. Firstly, painting can serve as a tool to express the emotion, thoughts, feelings and conflict, especially for those who do not have the chance to express their thoughts in words [
Possible explanations for inconsistency could be small sample size, heterogeneity in cancer population, measuring instrument and statistical methods [
Art therapist, playing an important role in the intervention, gives patients guidance including use of colors, subjects of drawing and technical options [
As a form of art therapy, painting therapy is suitable for patients with various diagnoses, ages and levels of education [
Although Geue et al. [
Geue et al. [
Considering that some participants found it hard to work in a group [
There were some limitations in this review. First, narrative synthesis was conducted owing to heterogeneity, which limited generalizability. Second, because of the small amount of literature on this topic, 3 studies extending from a same sample were all included which may cause the research outcomes less persuasive. Last, no effect size was presented because both quantitative and qualitative studies were included.
The study is the latest and the most comprehensive systematic review on paining therapy dependently in cancer population up to now. Various forms of painting therapy in cancer population have been summed up. The effects on participants have been analyzed. As an economical and convenient method, painting therapy is feasible in various types of cancer populations with positive effects on participants quality of life, coping with disease, mental health and somatic symptoms. We call for more randomized controlled trials with larger sample size in future studies. The effects on participants at different cancer stage and who benefits most should be explored. Studies on male participants should be paid attention to. Besides, different modes of painting therapy should be developed and compared.
This systematic review synthesizes the latest research evidence of painting therapy in adult cancer patients, lying a groundwork for future research in clinics. The results from the current study strongly support painting therapy as a powerful tool in rehabilitation of various types of cancer patients and painting therapy is feasible in daily practice, although the examination of the effectiveness of painting therapy in psycho-oncology is still relative young.
The authors declare no conflicts of interest regarding the publication of this paper.
Ding, Z.T., Ouyang, Y.Q. and Zhang, N. (2019) Painting Therapy in Cancer Care: A Descriptive Systematic Review. Open Journal of Nursing, 9, 89-102. https://doi.org/10.4236/ojn.2019.92009