This trial was conducted at the Yonsei Cancer Center, Yonsei University College of Medicine in collaboration with faculty from the Graduate School of Clinical Art Therapy, CHA University. We used a prospective design and received approval from the Institutional Review Boards of the Yonsei Cancer Center, Yonsei University College of Medicine. We recruited adult ambulatory patients of the Department of Radiation Oncology between January 2015 and April 2015. Eligibility criteria included the following: scheduled to receive 4 or more weeks of external-beam radiotherapy, older than 20 years, and able to understand questionnaires. Exclusion criteria included uncontrolled co-morbid medical or psychiatric illness, metastatic disease, poor performance (Eastern Cooperative Oncology Group [ECOG] > 2); and severe anemia (hemoglobin < 9 g/dL).

The therapy program utilized in this study involved the following elements: art therapy based on the appreciation of famous paintings conducted across four 15-minutes sessions once a week, as well as a one-to-one interview between the therapist and patient in a separate therapy room prior to radiotherapy. In order to reduce an anxiety for treatment room, art therapy was started before 30 minutes of radiotherapy appointment. The art therapy was conducted at least once a week for 4 weeks. The therapists and patients were randomly assigned in the first session, and the assigned pairs did not change throughout the program unless the patients had special wishes. Seventeen students, who major in art therapy, conducted art therapy and interviewed patients. In each session, one of the artworks was preselected as the object of therapy for that session. The patient expressed the feelings aroused by images of the painting, and the therapist inferred the patient’s emotional, affective, and mental states based on his/her predilection when choosing the artwork and expression of the emotions aroused by the image of the painting. Art therapists led the process of artistic expression and interviewed the patients with the following processes: first introduction part, 1) viewing famous paintings to arouse interest in paintings and explore the images offered by them; 2) talking about the experiences of seeing paintings similar to the one chosen by the patient; 3) talking about the reasons for choosing the painting. Second activity part, 1) exploring the aesthetic elements used in the painting (colors, lines, and spatial composition); 2) imagining the artist’s intention expressed through the painting; and 3) talking about the patient’s feelings on seeing the painting. Third conclusion part, 1) talking about the emotions felt before and after the activities. The famous paintings were selected by an expert panel of three and clinical art therapists who had experience of implementing three or more art therapy sessions. An important selection criterion was that paintings were easy to understand and interesting for patients. Questions to aid selection were as follows: Is the painting related to the topic? Are the expression techniques and contents related to the topic? Is the painting easy for the patients to understand? Can the painting attract patients’ interest? Can the painting evoke patients’ internal motives? Are aesthetic elements clearly expressed? The famous paintings consisted of a landscape painting in the first session, a figure paintingin the second session, a color-centered painting in the third session, and a Christian painting in the fourth session. Table 1 lists the selected paintings. A total of 21 famous paintings were used as therapy materials for the 4 sessions of the program. They were printed in resolutions of 300 dpi or higher and offered in real-size frames. The illumination of the therapy room was kept at the same level throughout the program. The paintings were placed at a distance of 50 cm from the patient, facing the therapist and patients in the same direction.

All the patients were asked to fill the questionnaires at baseline before starting radiotherapy, every week for 4 weeks during radiotherapy, and at the end of radiotherapy. Fatigue and QoL was assessed using the Brief Fatigue Inventory (BFI) and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F). The BFI was used for fatigue assessment and consists of 9 items that ask participants to rate the severity of current, usual, and worst fatigue and how much it interfered with their lives during the previous 24 hours. Fatigue and its interference are measured on a 0–10 scale, where 0 represents “no fatigue” and 10 denotes “as bad as you can imagine.” The BFI score is calculated from the mean of the 9 items. Higher scores on the BFI represent worse fatigue. The validity and reliability of the BFI has been established [23,24]. The FACIT-F contains 40 items, where are the Functional Assessment of Cancer Therapy (FACT-G) instrument and additional fatigue–specific items [25,26]. The FACT-G consist of 4 primary QoL domains: physical well-being (PWB; 7 items), social/family well-being (SWB; 7 items), emotional well-being (EWB; 6 items), and functional well-being (FWB; 7 items). The fatigue subscale (FS) contains 13 items. It generates FACIT-F trial outcome index (TOI), FACT-G total score, and FACIT-F total score. The total FACT-G score is obtained by summing individual subscale scores (PWB + EWB + SWB + FWB). The TOI is the sum of the PWB, FWB, and FS score. Total scores for FACIT-F are obtained by summing all subscale scores (PWB + EWB + SWB + FWB + FS score). Higher scores for the scales and subscales indicate better QoL.

A change was defined as the baseline value minus the value at each week during radiotherapy for each scale. Means and standard deviations were used to present the results. The overall impact of art therapy over time was evaluated using generalized linear mixed modeling for the BFI and each score from the FACIT-F. The mean values for scores at specific time points were plotted graphically. No adjustments for missing data were made beyond the use of generalized linear mixed modeling. All statistical tests were two sided, with significance level of 0.05.

Between January 2015 and April 2015, 50 patients were eligible and willing to participate in the study. Of these, only 34 (68%) participated in 2 or more sessions. Sixteen patients withdrew this study due to lack of interest. All 34 patients completed 4 sessions of art therapy. We analyzed the data of these 34 patients, which were appropriate for evaluate the effect of art therapy. Baseline characteristics are presented in Table 2.

The median age was 50 years (range, 34 to 68 years) and patients had a good performance status (ECOG, 0 or 1). Breast cancer patients were most common. There was no recurrent cancer patient and most patients had cancer treatment duration of less than 1 year. All patients received radiotherapy for curative, not palliative purposes. Baseline fatigue was mild to moderate with a mean BFI score of 3.1 (max, 10) and FS score of 39.1 (max, 52). However, 50% answered that they had fatigue irrespective of severity. There was no significant relationship between baseline fatigue and clinical factors.

Table 3 demonstrates change scores at weekly time points during radiotherapy. Fig. 1 and Table 4 show these findings for the BFI and each FACIT-F domain. Generalized linear mixed modeling testing for the effect of time on mean change scores showed no significant worsening of scores from baseline for BFI and FACIT-F. Although statistical significance was not reached, art therapy decreased mean BFI scores during radiotherapy (from 3.1 to 2.7). For the FACIT-F, most summed scores (FACIT-F TOI, FACT-G, and FACIT-total) showed a similar pattern. No statistically significant change was observed. However, 4 primary QoL domains of FACT-G and FS showed a different change patterns during radiotherapy. PWB and FS slightly decreased, indicating worse QoL. On the contrary SWB, EWB, and FWS slightly increased, indicating better QoL. There were no associations between clinical factors and change in fatigue score at any time point in generalized mixed model.

After the art therapy program was completed, a survey was conducted with the 34 patients who participated in all four art therapy sessions. The exit-interview questionnaire showed that all of patients indicated that the art therapy program was helpful and that they would recommend it to others. The item, “What is the most important thing that has happened?” in Table 5 was analyzed using the session notes that were used to record the progress of the art therapy program. It was found that the number for “express inner emotion” and “enhance and explore self-expression” were higher than those for other items, at 73 (24.8%), and 71 (24.2%), respectively. This indicates that the patients utilized the art as a medium through which they could reflect on their own mentality or situation, provide an opportunity for internal self-expression, and facilitate self-expression. However, “help take mind off pain or discomfort” (2.7%) was shown to be lower than most other items. The item “enhance coping mechanism” was also found to be lower than other items. The art therapy based on the appreciation of famous paintings led to increases in self-esteem by increasing self-realization and forming social relationships.