The Effect of Art Therapy in Women with Gynecologic Cancer: A Systematic Review

Objectives The purpose of this study was to evaluate the evidence of art therapy on the psychological outcome, quality of life (QOL), and cancer-related symptoms in women with gynecological cancer. Methods A systematic literature search was conducted. The randomized controlled trials, quasiexperimental studies, case reports, and qualitative studies were all included. Result 1,587 articles were retrieved. A total of 9 articles met the inclusion criteria. The existing studies provided initial evidence to suggest that art therapy may benefit gynecological cancer patients with respect to improving psychological outcome and QOL, reducing fatigue related to cancer, and improving subjective overall health condition. However, the quality of the current evidence limits the efficacy of these findings. Conclusion Research on art therapy of gynecologic cancer patients is insufficient. We cannot draw the conclusion that art therapy benefits gynecological cancer patients in the psychological outcome, QOL, and cancer-related symptoms. More rigorous research is needed.


Introduction
Cancer is an overwhelming experience for patients [1]. e diagnosis of cancer has not only obvious physical ramifications but also produces psychological stress as well [2]. Cancer patients are particularly vulnerable to depression and anxiety. ese disorders have a severely detrimental effect on the patient's quality of life [3]. Gynecologic cancers include any cancer of the female genital system: uterine, ovarian, cervical, vulvar, vaginal, and endometrial [2]. ese diseases seriously affect women's health. For example, cervical cancer is the fourth most common cancer in women, and the seventh overall, accounting for 7.5% of all female cancer deaths [4]. e patients with gynecological cancer may suffer from psychological distress, fatigue, sleep disturbance, urinary/bowel issues, lymphedema, menopausal symptoms, and sexuality issues [5][6][7]. Side effects of treatment, complications, and cumulative organ toxicities may alter the patient's body function, interfere with daily activities, have a negative impact on QOL [8], as well as distorting their psychological states, body image, body awareness, and selfesteem [2]. It was reported that nearly 90% of gynecological cancer survivors need supportive care [9]. Cancer patients are increasingly turning to complementary and alternative medicine (CAM) therapies to reduce symptoms, improve QOL, and boost their ability to cope with stress [10]. Art therapy is one of the complementary therapies being used to relieve cancer symptoms [11].
Art therapy is an umbrella term for therapies such as dance and movement therapy, music therapy, and art therapy working with visual arts materials. It is a clinical intervention based on the belief that the creative process involved in the making of art is healing and life enhancing [11]. Art therapy can provide a route of nonverbal expression; the process of creating art provides relief and support. e majority of art therapy research has involved patients with breast cancer, hematologic malignancies, and pediatric brain tumors [12]. Studies have provided encouraging evidence to utilize this technique. It has become increasingly popular in a number of medical and health fields [10]. Cancer patients participating in art therapy experience improvements in mental health, QOL, personal growth, or positive social interaction [13]. Studies have suggested that art therapy leads to increased awareness of self, improved ability to cope with symptoms, stress, and traumatic experiences [14].
Some systematic reviews have explored the effects of art therapy. For example, Tang et al. [1] reported that art therapy benefited female breast cancer patients with respect to relieving anxiety, depression, and fatigue. Wood et al. [15] found a positive effect of art therapy on psychological symptoms and QOL in adults with cancer. A review by Geue et al. [13] showed that art therapy benefited cancer patients in various ways, including improving their mental health. e review of Reynolds et al. [16] showed that three types of study designs produced similar results regarding the positive effects of art therapy, but inconsistency was found. A systematic review [10] suggested that arts therapies seemed to positively affect the anxiety of cancer patients but not depression or QOL. Besides, patients with different cancer types are heterogeneous in terms of sociodemographic factors, symptoms, treatment, and side effects [10]. Considering the characteristics of the disease and its impact on body image, fertility, and sexuality, art therapy focusing on gynecological cancer patients need to be explored specifically. To our knowledge, no review has specifically focused on this field. is systematic review aims to evaluate the evidence for the effects of art therapy on the psychological outcome, QOL, and cancer-related symptoms in gynecological cancer patients.

Assessment of Quality.
Two authors reviewed each type of study with the JBI Critical Appraisal Checklist [18]. Disagreements were resolved through discussion with the third author.

Data Extraction and Analysis.
Two reviewers independently extracted the required data, including participant characteristics, study methods, interventions, and outcomes. Randomized controlled trials included in the review were pooled in Meta-analyses using RevMan5.3 software program. Randomized controlled trials, quasiexperimental studies, case reports, and qualitative studies were discussed in descriptive comparisons.

Study Identification.
Our research identified 1587 items, of which 20 were relevant according to the title and abstract after duplicates were removed. 12 items were excluded based on the inclusion or exclusion criteria. 9 studies were eligible for the final review ( Figure 1). e included studies ranged from 2012 to 2019, including 2 RCTs, 2 quasirandomized trial, 2 qualitative research studies, and 3 case reports. General characteristics of the included studies were listed in Table 1.

Participant
Characteristics. e sample sizes ranged from 1 to 27. e participants of three studies [2,19,20] were patients receiving radiotherapy. Four studies [12,[21][22][23] focused on patients being treated with chemotherapy. e participants of one study [24] were newly diagnosed with gynecologic cancer patients. One eligible study [25] focused on patients who had been diagnosed for the first time with cancer and had received surgical treatment. e participants of four studies [19][20][21]25] included other cancer patients than gynecological cancers. e participant characteristics were summarized in Table 1.

Intervention.
ere was considerable heterogeneity in the study designs. e art interventions included music therapy, painting appreciation, drawing, creative artwork generation, printmaking, mandala, collage, storytelling combined with dancing and crafts, writing poems, and composing tone. e length of intervention sessions varied from 30 to 90 minutes, and sessions varied from a single to an average of ten. Six papers reported that art interventions were delivered by a therapist, and one paper reported the study was supported by a therapist. However, some papers did not report whether the therapist was involved in the research. Specific information including the length and frequency of each intervention was not described clearly either.

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Evidence-Based Complementary and Alternative Medicine

Outcome.
Alcântara-Silva et al. [20] found that individual music therapy sessions might be effective in reducing symptoms of depression and fatigue related to cancer, as well as to improve QOL for women with gynecological cancer undergoing radiotherapy. Lee et al. [21] identified that listening to recorded monochord sounds had positive effects on reducing anxiety and improving physical and psychological states during chemotherapy. According to Wiswell et al. [12], art therapy, consisting of drawing, printmaking, mandala, and collage, might help to prevent or mitigate the decline of QOL caused by chemotherapy in gynecological cancer patients. Lee et al. [19] found that art therapy based on famous painting appreciation and creative artwork significantly improved cancer-related anxiety and depression. e qualitative research conducted by Hammer et al. [24] indicated that drawing and later interviews might be a tool in understanding the hope of newly diagnosed gynecologic oncological patients. e research of La Cour et al. [25] demonstrated that the use of storytelling intertwined with dancing, arts, and crafts, provided the patients and their relatives with strategies to manage cancer-related concerns. Researchers [2] developed a clinical model of dance/ movement therapy for gynecologic cancer patients. ey did not research the efficacy in relation to clinical outcome variables, but evidence indicated the potential benefits of art therapy. e patient was able to gain insight into parts of herself and expressed being less isolated as well as more open to the support available from others. Findings of a research conducted by Ben-Arye et al. [23] suggested that music therapy may alleviate adverse symptoms of chemotherapy and improve patients' QOL. Lee et al. [22] found music therapy helped the patient to experience a decrease of negative feelings, an increase of the positive feelings, and improvement of subjective overall health condition.

Risk of Bias and Quality Assessment.
We assessed the methodological quality of the studies and the possibility of bias with JBI Critical Appraisal Tools. e nine eligible studies varied in design, requiring different quality appraisal methods.
e risk of bias and quality assessment of two RCTs is showed in Table 2. Table 3 shows the risk of bias and quality assessment of two quasiexperiments. e assessment of two qualitative research studies is listed in Table 4. Table 5 shows the assessment of three case reports.

Discussion
A total of nine studies were included in this review. Obvious heterogeneity of the eligible studies was observed, including research design, specific intervention method, and outcomes evaluation. For example, some studies used a single type of art intervention, while others included several types of arts. Interventions were implemented in different ways including individual or group formats. One study [25] involved the patient's relative to join, while other studies did not. e heterogeneity made it difficult to assess the studies quantitatively and generalize the findings. Consequently, the studies were qualitatively described. No overall effect size was determined. According to the current research evidence, positive results of art therapy were found. It showed that art therapy benefited gynecologic cancer patients with respect to psychological outcomes, such as anxiety, depression, and cancer-related concerns [19][20][21][22]25]. A positive effect on QOL was also observed [12,20,23]. In addition, there was evidence suggesting that art therapy was helpful to reduce fatigue related to cancer [20] and improve subjective overall health condition [22].
However, the methodological shortcomings limited the efficacy of these findings. For example, the sample size of eligible studies was small. e a priori power calculation for an adequate sample size was unclear. Among them, only one quasiexperiment study, one qualitative study, and three case studies especially focused on gynecologic cancer patients, while other studies included not only gynecological patients but also other cancer patients. Lack of high-quality randomized controlled study and the absence of intent-to-treat analyses also prevented the efficacy of the findings. In addition, art therapist is someone who has a large territory of knowledge including counseling, marriage and family therapy, art, education, community work, and creative expression and integrates these fields into a unique profession [26]. e way art therapy is perceived responses to the way it is conveyed [26]. However, six of the included studies reported that art intervention was delivered by the therapist, and one research was supported by the therapist. In two research studies [24,25], it was unclear whether the therapist   was involved in the study or the implementers had received professional art therapy training. In addition, surgery is a primary treatment for gynecologic malignancy [27]. For example, hysterectomy is one of the most common gynecological surgeries. Women undergoing this surgery often experience negative emotions. It may be a potent stimulus for stress and psychological problems [28]. In the present review, we noticed that most of the participants were receiving chemotherapy or radiotherapy patients. Evidence of art therapy in gynecological perioperative cancer patients was quite insufficient. Art therapy effectiveness research, including experimental and control group studies, is relatively new [26].

Evidence-Based Complementary and Alternative Medicine
Considering the quality of current evidence, we find that  6 Evidence-Based Complementary and Alternative Medicine   Evidence-Based Complementary and Alternative Medicine research on art therapy of gynecologic cancer patients is insufficient. We cannot draw the conclusion that art therapy benefits gynecologic cancer patients in the psychological outcome, QOL, and cancer-related symptoms. ere is much to be considered as to promoting art therapy in a medical setting, such as the patient's ability to move, level of verbal communication, disruptions by medical treatment, as well as the limitation of the medical environment [26]. Better integration of art therapy and medical activity to benefit gynecologic cancer patients needs to be explored further. Future research may target adequate samples, various art forms, and long-term follow-up to develop appropriate art interventions for gynecologic cancer patients receiving different treatments. Additionally, detailed sociodemographic and medical information should be taken into consideration; the mediator and moderator variables may be explored further.

Conflicts of Interest
e authors declare that they have no conflicts of interest.