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Running head: AN INTEGRATED APPROACH TO CANCER USING ART

THERAPY
1







An Integrated Approach to Cancer Using Art Therapy
Michelle Bittenbender
University of South Florida













AN INTEGRATED APPROACH TO CANCER USING ART THERAPY 2
Abstract
Art Therapy has proven to be successful in coping with pain management, stress
reduction and other significant improvements in quality of life for patients diagnosed
with Cancer. Currently Florida Hospital of Tampa has no such resources available for it‟s
clients. Is there evidence-based research to support an integrative approach to cancer
treatment? Can art therapy alleviate common cancer symptoms?
Search engines used to gather supporting research articles include PubMed and
the University of South Florida‟s Library Database. Key words included art therapy* and
cancer*. Publication dates were limited to 2007 to present.
Current research clearly supports the benefit of adjunct use of art therapy in
relation to traditional cancer treatment. Documentation of positive gains in psychological,
spiritual and physical cancer symptoms has proven its relevance to be included in the
clinical setting. There is no evidence that it causes any harm. A significant decrease in
pain and subsequent increase in quality of life was seen in patients who participated in art
therapy sessions. Art therapy fostered a sense of solidarity amongst its participants while
instilling a new sense of creativity and „conscious living.‟ These benefits may contribute
to overall sense of health and potentiate the success of traditional chemo and radiation
therapy.



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An Integrated Approach to Cancer Using Art Therapy
According to the National Cancer Institute, in the year 2013 there is expected to
be 1,660,290 new cancer cases diagnosed. This staggering figure will join the already
pre-existing 13.7 million Americans who are currently living with a cancer diagnosis
(American Cancer Society, 2013). The diagnosis and treatment of Cancer brings with it
significant anxiety, pain, fatigue, nausea and depression (Wood, Molassiotis, & Payne,
2011). Art Therapy poses a non-invasive solution to many of these issues. The purpose of
this review is to synthesize and assess current evidence based research for use of art
therapy as an intervention to address these common psychosocial difficulties. Further
more, art therapy may provide a holistic level of health when used in conjunction with
traditional interventions, thus increasing the efficacy of mainstream chemotherapy and
radiation. The question this synthesis strives to address is: In patients diagnosed with
cancer, what is the effect of art therapy on experiencing less pain and overall improved
quality of life compared with traditional chemo and radiation therapy, through the
duration of their cancer treatment?
Literature Search
Search engines used to gather supporting research articles include PubMed and
the University of South Florida‟s Library Database. Key words included art therapy* and
cancer*. Publication dates were limited to 2007 to present.
Literature Review
The articles used in this synthesis are outlined in Table 1. Svensk, preformed a
randomized control trial in 2009, to determine the efficacy of art therapy in relation to
improving experienced quality of life in 41 women diagnosed with breast cancer who
AN INTEGRATED APPROACH TO CANCER USING ART THERAPY 4
were undergoing radiotherapy. Participants were randomly assigned to an intervention
group, which would include a one-hour/week art therapy session, or to a control group. A
specific questionnaire (WHOQOL-BREF and EORTC Quality of Life Questionnaire-
BR23) was provided at three intervals throughout treatment, before initiation of
radiotherapy, and again at two and six month intervals. A significant increase in quality
of life was seen in the women who participated in the intervention group. These women
expressed a more positive outlook on life, better body image and had less systemic side
effects as opposed to the control group. Increases in physical and psychological health, in
addition to overall quality of life were indicative of the intervention group. Age, presence
of children and tumor qualifications were factored into this study. This study illustrates
the effectiveness that art therapy can be an integral part of routine practice for women
with breast cancer.
The use of a randomized control design for this study is indicative of its strength.
Participants were computer randomized and unaware of their assignment until after their
final enrollment. The quality of life questionnaire was provided during an interview and
was blindly offered to all participants regardless of group assignment. Researchers were
thorough in their investigation and reasoning was provided as to why one participant was
unable to complete the study due to incomplete data. Subjects were followed until six
months after their treatment, which served as an effective time frame to ensure results.
The control group was appropriate and continued their plan of care until hospital
discharge. Both the control and intervention group were similar in sociodemographics
and clinical variables and statistical tests were performed to determine baseline
differences between groups. The intervention was precise and reflected the clinically
AN INTEGRATED APPROACH TO CANCER USING ART THERAPY 5
significant outcome of improved quality of life. Since this study is focused primarily on
nursing intervention, the results are profound in that initiation in the clinical setting is
both feasible and low-risk.
In 2007, Nainis and Paice, published a study to determine the efficacy of a 1 hour
art therapy program in relation to pain control and other common cancer treatment
symptoms in adult patients diagnosed with cancer. The concluding evidence of this
article supports decreased pain and improved quality of life for those facing cancer
diagnosis. This study is inclusive of both male and female genders across a multi-ethnic
background, with the majority being Caucasian. The majority of cancer patients included
had either Leukemia or Lymphoma. The study included feedback on a broad spectrum of
cancer symptoms including pain, tiredness, nausea, depression, anxiety, drowsiness,
appetite, well-being and breathlessness.
Although this study is not a randomized control study, its findings are relevant in
supporting the use of art therapy in conjunction with standard medical care. Participants
were from an inpatient oncology unit of a large urban academic medical treatment facility
and were recruited over a four-month period. Fifty patients in total completed the study.
The Edmonton Symptom Assessment Scale was implemented to determine factors
effecting treatment and allowed participants to rate their symptoms on a scale of 0-10.
Thorough investigation and evaluation was provided to explain why other patients who
were initially approached with the study declined to participate. This study shows
evidence for the sufficiency of art therapy at reducing a broad spectrum of cancer
symptoms in a diverse population. It concludes that art therapy is an inexpensive, easy to
implement, non-invasive and widely accepted intervention for use in the clinical setting.
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In a 2008 study by Visser and Op‟Thoog, researchers launched an evaluation-and-
effect study to determine the efficacy of a learning module titled „Cancer and the Creative
Arts.‟ Participants, primarily women with breast cancer, were grouped into five groups of
35. Eight week sessions consisting of 2.5 hour classes were held. Prior to the
commencement, and upon conclusion of the course, participants completed a
questionnaire. The module fostered a sense of solidarity amongst its participants and
although their disease process remained, a new sense of creativity and „conscious living‟
was reported. Preliminarily, most participants joined the module in hopes of discovering
and expressing feelings, although, post-module the majority of patients not only found a
way to discover and express their feelings but also were better able to cope with their
disease. Further investigation could branch from this initial study and include the effects
of specific cancer staging (Stage 1 through Stage 4) in relation to the outcomes of this
study. Follow up studies might additionally address the long-term effects of attending
creative art therapy.
Synthesis
Current research clearly supports the benefit of adjunct use of art therapy in
relation to traditional cancer treatment. Both the research conducted by Svensk and
Visser and Op‟Thoog were exclusively gained from breast cancer patients whereas the
study by Nainis and Paice focused on leukemia and lymphoma diagnosis. It is relevant to
note that while the patient population varies, the findings of the studies were similar. This
suggests that art therapy is appropriate for a broad range of cancer diagnosis. Positive
gains have been documented in psychological, spiritual and physical cancer symptoms
which proves its relevance to be included in the clinical setting. Although current clinical
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guidelines do not include the benefits of complimentary programs such as art therapy,
there is no evidence that it causes any harm.
Art therapy is an intervention that can elicit an advantageous response at all
phases of cancer treatment and may continue to be a solution that is accessible to patients
beyond the scope of their inpatient experience. Patients who are exposed to art therapies
are better empowered, are able to care for themselves and can define themselves outside
the limitations of their diagnosis. Art therapy reinforces positive coping behavior,
increases self-esteem and encourages a sense of control. All of these aspects significantly
contribute to increased cancer survivorship. It is important to be aware of non-
pharmaceutical interventions to be used in conjunction with traditional cancer treatment
to facilitate healing on multiple platforms. Art therapy supports patients in a holistic way,
by encouraging strength of character while simultaneously alleviating detrimental effects
such as pain and fatigue. It serves as a complimentary approach to cancer treatment,
which may increase the effectiveness of traditional chemo/radiation therapy. To consider
the innate connection between the health of one‟s physical, emotional and spiritual body
in relation to the stressors of cancer diagnosis, art therapy offers a calming and
humanizing antidote to the stressful environment of oncology care.
The research included in this synthesis are excellent pioneer studies which evoke
further curiosity regarding future springboard studies that may isolate specific types of
cancer in relation to corresponding symptom management. It would be interesting to
investigate the effects of cancer staging (Stage 1 through Stage 4) in relation to the
outcomes of these studies. Further research would be able to take into account the
influence of setting and other ethnicity demographics. Follow up studies could address
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the long-term effects of attending creative art therapy. Art therapy research in cancer
settings is still in its infancy, yet the potential of its future findings is promising.
Clinical Recommendations
At this time Florida Hospital of Tampa does not implement any type of art
therapy. A neighboring hospital, Moffitt Cancer Center, hosts an exemplary Art in
Medicine Program, which serves as a local role model. Florida Hospital of Tampa could
initiate a smaller scale bedside art therapy program. Overhead costs would remain low
while increased healing time and decreased length of stay would facilitate customer
satisfaction and continuity of care.
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References
American Cancer Society. Cancer Facts & Figures 2013. Atlanta: American Cancer
Society; 2013.
Nainis, N. & Paice, J. (2007). Relieving symptoms in Cancer: Innovative use of art
therapy. Journal of Pain and Symptom Management, 31(2), 162-169.
doi:10.1016/j.jpainsymman.2005.07.006.
Svensk. A. (2009). Art therapy improves experienced quality of life among women
undergoing treatment for breast cancer: a randomized controlled study. European
Journal of Cancer Care. 18, 69–77. doi: 10.1111/j.1365-2354.2008.00952.x.
Visser, A. & Op‟Thoog, M. (2008). Education of creative art therapy to Cancer
patients: Evaluation and effects. Journal of Cancer Education, 23, 80-84. doi:
10.1080/08858190701821204.
Wood, M., Molassiotis, A., Payne, S. (2011). What research evidence is there for the use
of art therapy in the management of symptoms in adults with cancer? A
systematic review. Psycho-Oncology. 20, 134-145. doi: 10.1002/pon.1722.




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Table 1

Literature Review
Reference Aims Design and
Measures
Sample Outcomes /
statistics
Nainis, N. & Paice,
J. (2007). Relieving
symptoms in cancer:
Innovative use of art
therapy. Journal of
Pain and Symptom
Management. 31.(2)
162-169.
Determine the
efficacy of a one-
hour art therapy
program in
relation to pain
control and other
common cancer
treatment
symptoms in adult
patients diagnosed
with cancer.
Edmonton
Symptom
Assessment Scale
(ESAS) and the
state portion of
the Spielberger
State-Trait
Anxiety Index
(STAI-S) scores

n=50
Diagnosis was
cancer, were 18 or
older, were
cognitively intact,
were able to
communicate in
English, and were
capable of
participating in a
1-hour session of
art therapy.
Statistically
significant
reductions in eight
of nine symptoms
measured by the
ESAS.

Svensk. A. (2009).
Art therapy
improves
experienced quality
of life among
women undergoing
treatment for breast
cancer: a
randomized
controlled study.
European Journal of
Cancer Care. 18,
69–77.

Determine the
efficacy of art
therapy in relation
to improving
experienced
quality of life in
41 women
diagnosed with
breast cancer
undergoing
radiotherapy.
RCT

WHOQOL-BREF
and EORTC
Quality of Life
Questionnaire-
BR23
41 women
diagnosed with
breast cancer
undergoing
radiotherapy.
Significant
increase in quality
of life was seen in
the women who
participated in the
intervention group.

Positive outlook on
life, better body
image and less
systemic side
effects as opposed
to the control
group.
Visser, A. &
Op‟Thoog, M.
(2008). Education of
creative art therapy
to Cancer patients:
Evaluation and
effects. Journal of
Cancer Education,
23, 80-84.
Determine the
efficacy of a
learning module
titled „Cancer and
the Creative Arts.‟
premeasure and
postmeasure
questionnaire

Women with
breast cancer,
were grouped into
five groups of 35.
Positive changes in
emotions,
“conscious living,”
and the
development of
creativity were
reported.

Wood, M.,
Molassiotis, A.,
Payne, S. (2011).
What research
evidence is there for
the use of art
therapy in the
management of
symptoms in adults
with cancer? A
systematic review.
Psycho-Oncology.
20, 134-145
Assess and
synthesize the
available research
evidence for the
use of art therapy
in the management
of symptoms in
adults with cancer.

Questionnaires,
interviews,
patients’ artwork,
and stress
markers.

Fourteen papers
reporting 12
studies.
Emotional,
physical, social
and global
functioning, and
existential/
spiritual concerns

Art therapy
facilitates the
process of
psychological
readjustment to the
loss, change, and
uncertainty of
cancer diagnosis.