Accepted Manuscript

Title: A COMPARETIVE STUDY OF ART THERAPY IN

CANCER PATIENTS RECIEVING CHEMOTHERAPY
AND IMPROVEMENT IN QUALITY OF LIFE BY
WATERCOLOR PAINTING

Author: H. Bozcuk K. Ozcan C. Erdogan H. Mutlu M. Demir

S. Coskun

PII: S0965-2299(16)30330-2
DOI: http://dx.doi.org/doi:10.1016/j.ctim.2016.11.006
Reference: YCTIM 1641

To appear in: Complementary Therapies in Medicine

Received date: 27-1-2015

Revised date: 30-7-2016
Accepted date: 17-11-2016

Please cite this article as: Bozcuk H, Ozcan K, Erdogan C, Mutlu H, Demir
M, Coskun S.A COMPARETIVE STUDY OF ART THERAPY IN CANCER
PATIENTS RECIEVING CHEMOTHERAPY AND IMPROVEMENT IN QUALITY
OF LIFE BY WATERCOLOR PAINTING.Complementary Therapies in Medicine
http://dx.doi.org/10.1016/j.ctim.2016.11.006

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A COMPARETIVE STUDY OF ART THERAPY IN CANCER PATIENTS RECIEVING
CHEMOTHERAPY AND IMPROVEMENT IN QUALITY OF LIFE BY WATERCOLOR
PAINTING

Bozcuk H*, Ozcan K**, Erdogan C,** Mutlu H**, Demir M***, Coskun S**.

Hakan Bozcuk*: Dept. of Medical Oncology, Medical Park Hospital, Antalya, Turkey,
Kezban Özcan**, Cengiz Erdoğan**, Hasan Mutlu**, Şenol Coşkun**: Dept. of Medical
Oncology, Akdeniz University, Antalya, Turkey, ***: Meltem Demir: Dept. of
Biochemistry, Medical Park Hospital, Antalya, Turkey.

Adress for Correspondence:

Hakan Bozcuk, Dept. of Medical Oncology, Medical Park Hospital, Antalya, Turkey.
E-mail: hbozcuk@gmail.com
Mobile: 0090 505 6728038
Fax: 0090 242 3143030.
Highlights

 We show in a sample of 72 cancer patients that watercolor painting (PATP)

as a form of art therapy improves quality of life and depression. Moreover,
PATP is feasible in patients during their chemotherapy sessions. We advise
art therapy in general and PATP in particular for cancer patients while on
active treatment.

ABSTRACT

Background: There is limited data on the role of art therapy used in cancer patients.
We wanted to test the effect of painting art therapy provided by a dedicated
professional painting artist on quality of life and anxiety and depression levels in
patients having chemotherapy.

Methods: Cancer patients having chemotherapy in the day unit of a medical

oncology department of a university hospital were offered to take part in a painting
art therapy program (PATP). This program consisted of a professional painting
artist facilitating and helping patients to perform painting during their
chemotherapy sessions while they were in the day unit, as well as supplying them
painting material for home practice. The changes in quality of life domains of
EORTC-QLQ-C30 questionnaire and in Hospital Anxiety and Depression Scores
(HADS) were assessed before and after the PATP. These results were contrasted
with a reference group of cancer patients on chemotherapy but not taking part in
the PATP. In order to adjust for multiple comparisons of quality of life parameters
between patient groups, we utilized the Bonferroni correction.

Results: A total of 48 patients, of which 26 patients did and 22 did not have prior
exposure to PATP, were enrolled in the PATP. A control group of 24 patients who
did not have any PATP activity during the study period also took part in the study.
With PATP, there was significant improvement in global quality of life (F=7.87,
P=0.001), and depression scores (F=7.80, P=0.001).

Conclusions: To our knowledge, this is the largest comparative PATP experience in

cancer patients on chemotherapy and show that PATP is feasible in the clinics. Our
results confirm that art therapy in the form of painting improves quality of life and
depression in cancer patients having chemotherapy. This effect was more
pronounced in patients without any previous experience of PATP.
Keywords: Cancer, chemotherapy, quality of life, art therapy, watercolor painting
INTRODUCTION

Art therapy has been used in oncology with some degree of subjective benefit
reported by cancer patients (1-6). Although various forms of art therapy such as
music, painting, drama or dance / movement therapy have been used alone or in
combination, we do not have solid information about the effect of art therapy in
various dimensions of quality of life in patients with cancer. In particular, studies
have reported on heterogeneous cancer cases, interventions have not been standard,
various forms of art therapy have been used, and outcome measures reflecting
effectiveness of art therapy have been variable. Thus, it is impossible to know at this
stage, which forms of art therapy, if any, and in which group of cases, are more
beneficial in cancer patients. In addition, we know that quality of life in cancer
patients have different dimensions, and it would also be helpful to know which
dimensions could actually be targeted and improved by art therapy (7).

One would expect to see improved psychological well-being and ideally a global
improvement in quality of life with art therapy, if that kind of therapy really makes a
clinically meaningful impact in cancer patients. Also, potentially other dimensions of
quality of life could also be affected either directly by art therapy and / or by
lessening of side effects from chemotherapy. Therefore, in this report, we planned to
analyze in ambulatory cancer patients receiving chemotherapy if painting art
therapy, as a form of art therapy, independently improved quality of life in any of its
dimensions, and whether prior exposure to painting art therapy made any
difference in this regard.

MATERIAL AND METHODS

PATIENTS AND DATA COLLECTION:

Patients attending the outpatient chemotherapy unit of Akdeniz University Medical

Faculty in Antalya, Turkey were recruited into the study. The study period
comprised the period of 12 weeks between February, the 1st, and April, the 30th of
2013. Patients receiving chemotherapy at the outpatient chemotherapy unit during
the first 6 weeks of the study were briefly made aware of the study details, and were
offered to take part in the study. Patients accepting the offer were classified with
respect to their exposure of PATP and they formed the 1 st two groups: PATP without
previous exposure and PATP with previous exposure. During this period, patients
declining PATP but accepting to take part in the study formed the third or control
group. Patients were re evaluated after 6 weeks, for change in various dimensions of
quality of life. Each case was given EORTC-QLQ-C30 questionnaire at the beginning
and the end of the study(7). Likewise, anxiety and depression scores were
calculated according to Hospital Anxiety and Depression Scale (HADS)(8). Patient
and study details were obtained from the medical records and interviews with the
subjects. After the study period (12 weeks) no further follow up was planned.
PAINTING ART THERAPY:

One of investigators (C. Erdoğan) is an experienced art therapist with years of

dedicated painting art therapy work with cancer patients in tertiary and private
cancer centers. His method involves encouragement of cancer patients in
participation in watercolor painting, and facilitation of talks within the frame of a
group about the finished paintings with special emphasis on the symbolic nature of
those paintings, and expression of feelings and thoughts. The artist particularly used
watercolor painting, mainly because this was his primary medium of practice. In
addition, at the chemotherapy unit where the art therapy was carried out, this
material provided ease of use, lack of smell, and completion of projects in timely
manner.
Among the patients receiving painting art therapy, C. Erdoğan worked with each
case in person. Each case was given brief introductory information about the
technique of watercolor painting, and the material involved. During their
chemotherapy administration, patients were then allowed to make watercolor
paintings freely near their chemotherapy chairs within the chemotherapy unit and
during their chemotherapy administration. After the completion of paintings, each
patient was encouraged to elaborate about the meaning and subject of their
paintings. The patients were also given paints and paper for home study at their
convenience. The number of paintings they completed during the study period was
also recorded and served as a proxy for motivation related with the program.

STATISTICAL METHODS:

Changes in dimensions of quality of life were assessed among the 3 groups, and
these figures were compared by Analysis of Variance (ANOVA) testing using
Bonferroni correction. As multiple subdomains of quality of life and various related
parameters existed, and each was tested separately for any difference across the 3
groups, a more strict P value of 0.01 was initially chosen, and because of the
presence of 3 groups, this figure was then reduced to 0.003 for significance in the
ANOVA testing. The predictors of scores of the significant parameters from the
ANOVA tests (with a P value of less than 0.003) were then evaluated for each
significant parameter using multivariate linear regression analysis. Significant
factors after the univariate analysis were selected by multivariate testing by using a
Forward Likelihood Ratio. A P value less than 0.05 was deemed necessary for
significance in the multivariate testing.

RESULTS

GENERAL CHARACTERISTICS

A total of 97 cases took part in the study and 65 had PATP, where as 32 (33%)
served as a control group and did not have PATP. Mean age was 50.6, and 56% were
female, majority had metastatic cancer (54%). Of the subjects, 41% had primary
school education, only. A mean figure of 7.9 cycles of chemotherapy had been
utilized prior to study entry in the whole group. See Table 1 for details.

THE EFFECT OF PATP ON QUALITY OF LIFE, ANXIETY AND DEPRESSION

All patients taking part in PATP declared they liked or enjoyed PATP to some extent.
Among the 3 groups, change in global quality of life (GQOL) and depression scores
differed significantly (F=7.87, P=0.001, and F=7.80, P=0.001, respectively). The
change in scores in the PATP group with previous exposure, the PATP group
without previous exposure, and the group not having PATP were 8.3, 25.5, and -
11.5 for global quality of life, and -0.2, -2.6, and 1.5 for depression. Refer to Table 2
for additional information.

By univariate analysis, the predictors of the change in GQOL were participation in

PATP (F=7.87, P=0.001) and baseline GQOL scores (F=27.72, P<0.001). Although
compliance to PATP at home (as a proxy for motivation) had a P value of 0.011 in
the univariate analysis, the significance disappeared during the multivariate
analysis (P=0.212). On the other hand, the correlates of change in depression were
again participation in PATP (F=7.75, P=0.001), and baseline depression scores
(F=17.71, P<0.001).

Likewise, the predictors of the magnitude of change by multivariate analysis for

GQOL were participation in PATP (F=6.08, P=0.004) and baseline GQOL scores
(F=36.51, P<0.001). Respectively, the correlates of change in depression were again
participation in PATP (F=11.11, P<0.001), and baseline depression scores (F=23.89,
P<0.001), respectively. Please, go to Table 3, and Figures 1a, 1b, 2a and 2b for
further details.

DISCUSSION

We showed improved quality of life and relief from depression in cancer patients
with the utilization of PATP. These improvements have not been reported in cancer
patients before especially within the framework of a prospective study. Previous
reports have focused on different types of art therapy and reported subjective
improvements in general well being of cancer patients (9-14). However , our study
specifically utilized watercolor painting as a form of PATP, and in general, of art
therapy, and prospectively evaluated effects of this intervention on quality of life
with reference to a control arm not receiving PATP. Therefore, this finding
highlights the importance of watercolor painting as a form of art therapy in
maintaining quality of life and well being of cancer patients.

We believe art therapy support, especially in the form of watercolor painting, is

feasible in daily practice, and should not be denied from cancer patients receiving
active cancer treatment. Interestingly, patients derived benefit from PATP in close
relationship with the basal global quality of life and depression scores. In PATP, the
patient's elaborations of meaning and subject of their paintings enabled catharsis of
negative feelings, and sharing and discussion of associated problems, feelings and
thoughts. In addition, we think being in a group, where social interaction is possible
and valued, also helped with the patients’ quality of life. Unexpectedly, patients with
poorer well being, i.e. those who had lower GQOL or higher depression scores, were
the ones that had better improvements by participating in PATP. Therefore, in
clinical practice, PATP may be expected to benefit those cancer patients who are
relatively in more need of help. On the other hand, previous exposure to PATP
appears to diminish the benefit obtained by the program. This is evident in the
lesser amount of improvement in GQOL and depression scores in patients with prior
exposure to PATP with reference to those without prior exposure to PATP.

This study has some limitations. Firstly, this study was not randomized. Also, the
control group consists of patients declining to join the treatment. This might have
biased the sample. Secondly, there is a difference in basal depression scores among
the groups. For this reason, multivariate tests of associates on the change of
depression scores and global quality of life, controlling for basal depression scores
and also of basal global quality of life, was carried out as illustrated in Figure 3. In
addition, the effect of PATP on global quality of life and depression in cancer
patients while on chemotherapy may be confounded by a number of factors, like
gender, anxiety levels, motivation status, as well as other patient, treatment or
disease factors. Our sample size did not allow us to study the interaction between
potential factors and usage of PATP. It is also theoretically possible that our cases
could have perceived less of chemotherapy side effects after PATP. Lastly, using the
number of paintings finished by each subject may be misleading as the only
indicator of motivation, because quality of paintings as well as total time spent for
completion of these paintings may also provide additional information on the
subjects’ motivation level. The use of different ways of assessing the level of
motivation of the participants needs to be assessed in further studies.

It remains to be explored which art therapy is more effective than others to better
quality of life in cancer patients. Because art is a subjective experience, it is possible
that different forms of art therapy may target different patients more specifically.
This possibility is reflected by improvement in well being in different patient
populations via many different forms of art therapy in the literature.

In short, we show in this paper that watercolor painting (PATP) as a form of art
therapy improves quality of life and depression in cancer patients. Moreover, PATP
is feasible in patients during their chemotherapy sessions. We advise art therapy in
general and PATP in particular for cancer patients while on active treatment. We
also call for randomized clinical trials to further comment on this issue.
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Figure Captions

Figure 1a. Involvement in Painting Art Therapy Program (PATP) and change in
global quality of life.

Groups:…… PATP with previous exposure, ………PATP without previous

exposure, No PATP.
Figure 1b. Involvement in Painting Art Therapy Program (PATP) and change in
depression

Groups:…… PATP with previous exposure, ………PATP without previous

exposure, No PATP.
Figure 2a. Change in global quality of life with respect to basal global quality of life
score
Figure 2b. Change in depression score with respect to basal depression score
Table 1. Patient, Disease and Treatment Characteristics

Group 1 (Patients having Group 2 (Patients having Group 3 (Patients not All
painting-art painting-art therapy having painting- patients
therapy
with previous without previous
exposure) exposure) art therapy)
Mean Mean n Mean Mean
Factors n ( %) (SD) Min Max n ( %) (SD) Min Max (%) (SD) Min Max n (%) (SD) Min Max
34 31 32 97
Number of subjects (35) (32) (33) (100)
22 20 12 54
Gender (female) (65) (65) (38) (56)
48.8 48.1 54.8 50.6
25 22 73 22 73
Age (11.4) 22 68 (10.4) 71 (10.4) (11.0)
Education level 13 10 15 38
(primary school)* (39) (35) (48) (41)
Type of housing 23 16 22 61
(owning) (70) (55) (79) (68)
Income (monthly
income of 0 to 400 US 13 30
Dollars)** 8 (27) 9 (31) (42) (33)
Perception of social
support (Feels 24 28 22 74
sufficient) (73) (90) (71) (78)
Religious belief (on an 4.4 4.2 3.8 4.1
2 1 5 1 5
ordinal scale of 1 to 5) (0.7) 2 5 (0.8) 5 (0.9) (0.8)
Type of cancer (Breast 10 5 22
Cancer) 7 (21) (32) (16) (23)
Stage of cancer (stage 19 16 17 52
4) (56) (52) (53) (54)
 Cycle of 11.1 6.2 5.8 7.9
1 1 16 1 47
chemotherapy*** (10.6) 2 47 (6.3) 22 (4.1) (8.0)
Participation in
Painting Art Therapy 34 31 65
Program (PATP) (100) (100) 0 (0) (67)
Compliance to PATP 5.0 3.0 2.7
1 n/e n/e 0 15
at home$ (3.2) 1 15 (1.7) 8 n/e (3.0)
Global quality of life
58.9
score at the onset of 59.4 56.5 8.3 60.8 16.7 100 0 100
(21.2)
study (23.4) 0 91.7 (20.7) 83.3 (19.9)
Depression score at 5.2 5.8 6.5 5.8
0 16 0 17 0 17
the onset of study (4.0) 0 15 (4.2) (4.4) (4.2)
*; Classified as no education, primary school, middle school, lycee, university, **; Ranked in US Dollars as monthly income of 0 to 400, 401 to
750, 751 to 1500, 1501 to 2500, more than 2500, ***; Total cycles of all chemotherapy protocols recieved, $; Number of paintings finished at
home until next visit to the chemo-therapy unit.
Table 2. The effect of painting-art therapy on scores of quality of life, anxiety and depression

Change in the magnitude of scoresΩ

Group 2 (Patients Group 3
having painting-art (Patients not
Group 1 (Patients having painting-art therapy having
without previous painting-art
exposure)(Mean therapy)(Mean F
Factors therapy with previous exposure) (Mean (SD) (SD) (SD) value P value
Global quality of
life scale* 8.3 (20.7) 25.5 (20.8) -11.5 (29.6) 7.87 0.001***
Functional
scales*
Physical
functioning -0.3 (7.8) 6.7 (11.6) -0.3 (10.9) 3.34 0.041
Role functioning -3.1 (21.7) 0.8 (17.9) -1.5 (27.9) 0.17 0.845
Emotional
functioning 10.8 (22.1) 6.8 (16.8) 2.2. (26.7) 0.92 0.403
Cognitive
functioning 6.2 (18.0) 9.9 (17.6) -1.5 (32.5) 1.37 0.262
Social
functioning 7.1 (23.2) 4.8 (35.0) 5.3 (24.3) 0.05 0.956
Symptom
scales*
Fatigue -11.1 (26.2) -14.1 (24.1) -1.0 (26.8) 1.73 0.186
Nausea and
vomiting -14.2 (30.1) -7.9 (23.9) -1.5 (25.1) 1.37 0.261
Pain -6.3 (18.9) -9.9 (21.0) -7.3 (39.5) 0.10 0.905
 Dyspnea -2.5 (20.5) -9.1 (23.4) 0.0 (31.8) 0.77 0.468
Insomnia -8.6 (35.3) -16.7 (17.1) -10.2 (39.5) 0.40 0.670
Appetite -3.9 (30.3) -15.2 (30.4) -7.3 (38.9) 0.71 0.497
Constipation -12.8 (35.4) 0.0 (34.1) -2.9 (30.0) 1.00 0.375
Diarhea -13.3 (33.3) -9.1 (23.4) -13.0 (34.4) 4.90 0.010
Financial
difficulties -3.7 (29.7) -13.6 (32.0) 4.2 (30.0) 1.96 0.149
HADS scores**
Anxiety score -0.5 (2.4) -2.1 (3.0) 0.3 (3.7) 3.65 0.031
Depression score -0.2 (2.4) -2.6 (3.0) 1.5 (4.7) 7.80 0.001***
*Scales of EORTC QLQ-C30 questionairre, ** Hospital anxiety and depression scale scores, ***Significant after Bonferroni correction
(P<0.003), ΩChange in scores is expressed over a scale of 100.
Table 3. Correlates of change in global quality of life and depression in cancer patients recieving chemotherapy
Change in global quality of
life Change in depression
Univariate Multivariate Univariate Multivariate
Tests Tests Tests Tests
F P F P F P F P
Factors value value value value value value value value
Gender (female vs. male) 2.29 0.135 0.74 0.394
Age 0 0.986 1.36 0.247
Education level* 1.15 0.288 0.80 0.376
Type of housing (owning vs. renting) 1.43 0.236 1.57 0.215
Income** 1.27 0.264 3.44 0.068
Perception of social support (absent vs. insufficient vs.
sufficient) 3.12 0.082 2.30 0.135
Religious belief (on an ordinal scale of 1 to 5) 0.73 0.397 0.10 0.758
Stage of cancer (stage 4 vs. 1 to 3) 0 0.992 0.67 0.416
Cycle of chemotherapy*** 0.03 0.855 0.33 0.568
Participation in Painting Art Therapy Program (PATP) 7.87 0.001 6.08 0.004 7.75 0.001 11.11 <0.001
Compliance to PATP at home$ 6.80 0.011 1.59 0.212 1.59 0.212
Global quality of life score at the onset of study 27.72 <0.001 36.51 <0.001 3.62 0.061
Depression score at the onset of study 0.17 0.678 17.71 <0.001 23.89 <0.001
*; Classified as no education, primary school, middle school, lycee, university, **; Ranked in US Dollars as monthly income of 0 to 400, 401 to
750, 751 to 1500,1501 to 2500, more than 2500, ***; Total cycles of all chemotherapy protocols recieved, $; Number of paintings finished at
home until next visit to the chemo-therapy unit.