Background

Cancer is the leading cause of death in Canada and is responsible for 30% of all deaths.1 According to the Canadian Cancer Society, an estimated 191,300 new cases of cancer and 76,600 deaths from cancer occurred in Canada in 2014.2 A cancer diagnosis and subsequent treatment entails profound changes in peoples' lives that require significant adjustment and extensive coping skills. Approximately one-third of in-patients and one-quarter of out-patients suffer from psychosocial distress (e.g. depression, adjustment disorder and anxiety) associated with cancer or its treatment.3

Psychosocial distress can be defined as "a multifactorial unpleasant emotional experience of psychological (cognitive, behavioral, emotional), social and spiritual nature that may interfere with the ability to cope with cancer".4^(p.2) Distress arises from an individual's efforts to adjust or cope with the impact of cancer.

In a study conducted by Lin and colleagues,5 art was shown to improve self-consciousness and resilience through personal growth within the context of palliative care. Participants engaged in visual fine art appreciation and hands-on painting. Using a quasi-experimental design, both appreciation and hands-on participation in painting were evaluated according to the patients' feelings, cognitions and behaviors. In a systematic review exploring the effectiveness of art therapy as an intervention tool among breast cancer participants, narrative analysis highlighted no overall effect size due to the heterogeneic nature of the studies despite its use across all stages of cancer.6

As a form of psychotherapy, art (visual, expressive, performance) has been used within health and social care for over 60 years.6 Research findings from three studies (qualitative, quantitative and a literature review) suggest that a person's life could become more meaningful and active by engaging in art appreciation and/or creating artwork.5,7,8 For some, a verbal expression of concern may be challenging particularly where disease, surgery or treatment impedes communication and disrupts self-image. Art may provide a useful bridge for communication and expression of psychosocial concerns within a therapeutic relationship wherein participants use a choice of visual art materials in an expressive manner to facilitate insight, increase self-agency and promote wellbeing.9-11

Art in various forms has been used as an intervention to offer support to cancer patients at different stages of their illness.6 In general, results have indicated a reduction in anxiety, stress, depression and physical symptoms, a general enhancement in quality of life and global health, and an increase in energy and positive disposition.7 Over the past 15 years, art therapy has increased as an innovative and supportive adjunct to psycho-oncology for enhancing psychosocial health and wellbeing among cancer patients across the continuum of disease.12

It has been suggested that "through image-making and reflection on their images, [cancer patients may be] able to give legitimacy to their own interpretations and experiences"13^(p.75) leading to the generation of a new sense of self, redefine relationships and engage in active self-care and symptom management.6,11 One striking example is the work of Frida Kahlo, considered one of the 20th century's most important artists. She was able to depict her own personal experiences of pain, suffering and disease.14 Alternatively, art such as the work of Gray and colleagues, which explored the metastatic breast cancer experience through a play, created a space for dialogue to occur and an opportunity to defuse socio-cultural myths and stigma associated with breast cancer.15,16 In another example of the use of art to generate meaning, researchers worked with sculptors and two breast cancer survivors to create three-dimensional torsos that were then used to explore the role of femininity, meaning and body image following mastectomy.11,17 Creative expression, such as the sculptures in this study, resulted in enhanced self-awareness and self-transformation by "cultivation of the imagination and attention to inner emotional experiences [horizontal ellipsis] and an exploration of the meaning of [cancer patients] lives".11^(p.209)

Despite the frequent use of art within psychotherapeutic practice and the prevalence of studies suggesting the benefits of integrating art into psychotherapeutic practice, research that evaluates the perceived effectiveness of art as an intervention in decreasing emotional distress, enhancing adjustment and improving coping among cancer patients, is still in its infancy.17 A preliminary review of the literature using CINAHL, PubMed and the Cochrane Collaboration resulted in three systematic reviews relevant to our topic (outside of music). No systematic reviews on this topic were found in JBI Database of Systematic Reviews and Implementation Reports. Two reviews undertook a meta-analyses of clinical trials involving art therapy and its effect on symptoms17,18 and one meta-synthesis focused on cancer and art therapy.6 What appears lacking are meta-syntheses that explore the role of art beyond art therapy to facilitate the generation of meaning and purpose following cancer diagnosis, treatment, recurrence and/or palliation, whether or not differences exist across gender and time and perceived differences in the generation of meaning exist whether one is the consumer or the creator of art. Therefore this systematic review will attempt to fill this gap, and explore the role and perceived usefulness of art as a mechanism to facilitate the generation of meaning among adult cancer patients across the disease continuum. More specifically, this review will determine whether individuals with a diagnosis of cancer, who are at any point along the continuum of care or treatment for cancer, perceive positive change in creating meaning out of the cancer experience.

Art and disease

Although art exists in many forms, the essence of art, regardless of whether the cancer patient is the creator or the consumer of art, can be conceptualized as a creative expression and form of communication that conveys messages among individuals and groups of people. "Art allows an individual to receive another person's expression of feelings and experience and, in turn, may feel those same emotions and thoughts".11^(p.204) Although literature that examines the role of art consumption as a therapeutic tool is limited, increasing research suggests that visual, performing and literary arts serve a role in allowing greater understanding of the illness experience.11 For example, storytelling has existed for centuries as a medium for sharing the illness experience and disseminating knowledge. Many people and cultures use stories and storytelling to convey a wide variety of information - from Aboriginal dreamtime myths in Canada to Southwestern Korean p'ansori (storytelling through music).19,20 Although science often dismisses stories as mere entertainment, having only subjective and minimal value, stories play a significant role in informing how lives, customs, caring and values are experienced and lived out.21,22

Stories, as a medium, are able to present more than just cold, hard facts; they capture the listeners' attention and appeal to a more human, emotional side of understanding. Stories are also able to bring complex technical language to a more comprehensible level.21,23 That is, stories allow for a more personalized learning experience, wherein each individual takes what she/he needs from the narrative. Individuals are challenged to reflect on the stories and their relevance on a deeper more meaningful level when the stories raise questions that deepen and enhance synthesis of knowledge. For health professionals, using this knowledge to inform practice has a great potential to improve the quality-of-care delivery.24

Expressive therapy has come to denote a variety of therapeutic art forms ranging from poetry and narrative, to drama, dance/movement, play, to art (e.g. photography, sculpture, paintings).25 Expressive therapy supports a connection between mind and body through self-expression to enhance emotional wellbeing, generate new meaning and improve physical health.26 The very process of creating art affords the creator a space within which thoughts, emotions and feelings can be expressed more easily by moving outside of the normal boundaries of speech.7 Such metaphorical symbolism can be relaxing, empowering and cathartic.27 Photography may provide the key to opening up dialogue. Plays may connect large groups to support understanding through reflection by taking the observer beyond the superficial to challenging myths, misperceptions, attitudes and socio-cultural norms.

Although it is important that art as a psychotherapeutic tool be delivered only by those with the appropriate education and training, nurses may draw on the principles of art to more effectively enhance their relationship with cancer patients. For example, the use of visual art (e.g. photographs and drawings) may be a viable mechanism for assisting individuals to engage in conversation about their experience with the nurse. Additionally, within nursing education, art may be integrated as a pedagogical tool to enhance understanding of the meaning of the cancer experience. For example the learning experience of nursing students may be enhanced by drawing on the use of digital stories, drawings and performance art as an educational vehicle to explore complex, challenging and emotional issues. Art may also afford a rehearsal opportunity for patients, families and nurses to connect, engage and open up more effective, supportive communication around issues such as palliative care, death and dying. Exploring the experiences of cancer patients as consumers or creators of art will be helpful in increasing our understanding of the role of art in supporting quality of life and its potential benefits as an intervention tool in providing supportive psychosocial care.

Inclusion criteria

Types of participants

Study participants will be all adults with cancer (18 years or above) from diagnosis to end of life and including cancer survivors who have engaged in the creation of art or as a consumer of art. All types of cancers will be included to ensure maximum representation.

Types of intervention(s)/phenomena of interest

This review will consider all qualitative studies that investigate how art contributes as a psychotherapeutic tool to making sense of the cancer experience, whether this art is created by the person with cancer or the person is the consumer of art. For the purpose of this review, art is defined as the expression of human creativity and imagination. Art includes the visual arts such as paintings, sculptures, documentaries and drawings; the expressive and dramatic arts such as poetry, literature, plays, vignettes and illness narratives as well as auditory/sensory such as music. All forms of visual, expressive and dramatic art will be considered for this study; however, because the effects of music and music therapy have been well studied, studies involving music will not be included. The benefits and/or challenges of integrating art whether as creator or consumer to make sense of the cancer experience and create meaning will be investigated.

Context

The contextual aspects of cancer on mental and psychological health will be explored, that is, making meaning, adaptation, mindfulness, resilience, coping with grief, bereavement and trauma. The setting for the intervention includes in-patient, out-patient/ambulatory and community.

Types of studies

We will include all qualitative articles related to phenomenology, narrative, storytelling, ethnography, grounded theory, participatory action research, feminist social construction, critical social theory and social construction that focus on art as a mechanism or tool for facilitating the generation of meaning out of the cancer experience including changing attitudes and beliefs to support adjustment and reduce the likelihood for psychosocial distress (e.g. depression, anxiety, adjustment disorder).

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Third, the reference list of all identified reports and articles will be searched for additional studies. Studies published in English between 2000 and 2015 will be considered for inclusion in this review as a preliminary scan of the literature revealed that there were no articles relating to this topic prior to 2000.

The databases to be searched include MEDLINE (OVID), Embase (OVID), CINAHL, ProQuest Nursing and Allied Health Source, Web of Science, PsycINFO, Evidence-Based Medicine Reviews (OVID) and the International Bibliography of Theatre and Dance.

We will review reference lists, hand-search therapy and topics journals that are identified during the search process as being the most relevant, and contact experts as needed. Search results will be downloaded into bibliographic software wherein duplicates will be removed in preparation of the screening process. The search results will be scanned by the librarian for obvious exclusions, and the remaining articles will be screened by reviewers for selection and data extraction. The bibliographies of these articles will also be searched for potentially eligible studies.

The selection of studies will occur in two stages. Stage one will involve a review of all identified titles and abstracts to determine if they meet the inclusion criteria. Stage two will involve the review of full-text articles for those studies deemed to meet the criteria or those where a decision cannot be made based on assessing the title or abstract alone. A PRISMA flow diagram showing the number of citations remaining at each stage of the review process will be created.

The search for unpublished studies will include Google Scholar, iMediSearch and Health on the Net as well as ProQuest Dissertations and Theses. In addition, we will search cancer-specific not-for-profit organizations (e.g. Canadian Breast Cancer Foundation) and cancer treatment centers (e.g., M.D. Anderson). We will also speak with experts in the field of psycho-oncology on this topic to identify possible unpublished articles and reports.

Initial keywords to be used will include art and art therapies, cancer, cancer care settings, healthcare workers, oncology, malignancy, metastases, palliative care, end of life, cancer survivor, meaning, psychosocial distress, depression, anxiety, adjustment and coping. Synonyms and terms related to these concepts will be identified and included in the search.

The following is a sample MeSH search to be run in MEDLINE (OVID). Searches in other databases will use equivalent subject headings wherever applicable and keywords identified as described above, taking into account the syntax of each database.

MEDLINE (OVID) subject heading search

Population: exp neoplasms/or oncology nursing/or "hospice and palliative care nursing"/or oncology nursing/or palliative care/or terminal care/or hospice care/or palliative medicine/or medical oncology/or radiation oncology/or oncology service, hospital/or cancer care facilities/or hospices

Intervention: art/or human body/or anatomy, artistic/or paintings/or portraits as topic/or sculpture/or literature/or anecdotes as topic/or biography as topic/or autobiography as topic/or famous persons/or personal narratives as topic/or drama/or Psychodrama/or literature, medieval/or literature, modern/or mythology/or poetry as topic/or "wit and humor as topic"/or narration/or art therapy/or sensory art therapies/or acoustic stimulation/or aromatherapy/or color therapy/or narrative therapy/or virtual reality exposure therapy/or recreation therapy/or play therapy/or bibliotherapy/or recreation therapy/or writing/

Assessment of methodological quality

The articles selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review using the standardized critical appraisal instrument from the JJBI Qualitative Assessment and Review Instrument (JBI-QARI) (see Appendix I). This software will provide the guiding framework for critically appraising the quality of studies to determine whether to include or exclude them for final analysis. A set of 10 core questions will be used. Quality assessment provides a threshold whereby studies are included or discarded, and facilitates an assessment of the relative strength/weakness of the evidence based on the study design.28 In the event of disagreement between the reviewers, further discussion or a third reviewer will be used to resolve the disagreement.

Data extraction

Data will be extracted by both independent reviewers from articles included in the review using the standardized data extraction tool from JBI-QARI (see Appendix II). The extracted data will include specific details about the phenomenon of interest, populations and study methods related to the review question and objectives.

Data synthesis

Once all data has been extracted, analysis of the included articles/manuscripts/studies will be undertaken using JBI-QARI.

The findings will be pooled using JBI-QARI. This will involve the aggregation of findings to create a core set of themes reflective of the aggregated findings. They will be sorted and grouped based on similarities in meaning of findings. The aggregated findings will be summarized to produce a single comprehensive set of synthesized findings relevant to the research question.

Acknowledgements

The authors would like to express their appreciation to the Nursing Research Fund, Dalhousie University, Canada, for supporting this research initiative. They would also like to thank Queen's Joanna Briggs Collaboration and York University for their guidance and support.

Appendix I: Appraisal instruments

QARI appraisal instrument

Appendix II: Data extraction instruments

QARI data extraction instrument

References