Introduction

Cancer is a stressful diagnosis that can be life-changing. Diagnosing cancer can provoke feelings of anger and anxiety, and in case the disease-induced emotional burden exceeds the individual’s potential to cope, it can result in psychological traumas [1,2,3]. Although medical treatments like surgery, chemotherapy, and radiotherapy can be effective in treating tumors, such treatments are not only ineffective in treating the patients’ psychological effects but also leave their side effects which in turn negatively affect satisfaction with cancer care and the quality of life for the sufferers and families [4]. Chemotherapy is one of the main cancer treatments, which has several complications such as fatigue, nausea, vomiting, constipation, or diarrhea [1, 5, 6]. Thus, it is highly important to optimize the quality of life of the patients during and after treatments such as chemotherapy.

Complementary and alternative medicine treatments have turned into the main part of supportive care for cancer sufferers. Art therapy has been introduced as one of the recommended treatments for reducing stress and anxiety in patients undergoing chemotherapy. Art therapy is a creative art-making process pursuing the goal of improving the psychological, physical, and emotional health of those afflicted with chronic maladies and disabilities, which helps the sufferer to develop interpersonal skills and relieve stress by involving creative artistic processes and gain personal insight by boosting self-esteem [7]. The effects of the intervention on the quality of life, anxiety, depression, and distress in the patients under chemotherapy have been analyzed [1, 8, 9]. Yet, so far, little information has been ah hand about the art therapy-induced effects on the mental health of the cancer sufferers undergoing chemotherapy. Among many psychological consequences of cancer patients, depression, anxiety, and patient’s quality of life are more and more commonly affected.

Therefore, the current study targets to review the existing studies on the art therapy-induced effect on depression, anxiety, quality of life, and distress in cancer patients undergoing chemotherapy.

Methods

The systematic review was according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyzes (PRISMA) checklist [10].

Search strategy and inclusion criteria

A systematic search of online electronic databases including, PubMed/MEDLINE, Scopus Web of Science, PsycINFO, and EMBASE was performed using keywords extracted from Medical Subject Headings such as “Art Therapy,” “Neoplasms,” “Cancer,” and “Chemotherapy” from the earliest to January 11, 2023. Search terms were adjusted for each database specifically and can be found in Supplementary Material. Keywords were combined via Boolean operators (AND/OR). All search steps were conducted by two researchers, independently. Studies including adults above the age of eighteen with cancer who are on chemotherapy involved in art making employing depression, anxiety, QoL, and psychological distress as outcomes. The gray literature including conference presentations, expert opinion, dissertations, research and committee reports, and ongoing research was ignored, due to the lack of accurate findings. Gray literature is papers that are produced in print and electronic formats but are not evaluated by a commercial publisher [11].

Study selection

Data management was performed using EndNote X8 software. Study selection was conducted based on inclusion/exclusion criteria through the following steps: [1] remove duplicate articles, first electronically and then manually; [2] evaluate the title and abstract of the study; and [3] assess the full text of the articles. Finally, a reference list of eligible studies was assessed to prevent the loss of relevant data. The third reviewer evaluated the paper in the presence of disagreement between the two researchers (Fig. 1).

Fig. 1
figure 1

The flow diagram of the study selection process

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Data extraction and quality assessment

The research team extracted the following information from the included studies: the name of the first author, year of publication, location, ward, sample size, male/female ratio, age, single/married ratio, level of education, work experience, death of a close relative in the last six months, questionnaire, and key results. The two researchers evaluated the quality of the included studies using a 20-item tool called the appraisal tool for cross-sectional studies (AXIS tool), as shown in Figs. 2 and 3 [12].

Fig. 2
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Methodological quality assessment of RCT studies using JBI

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Fig. 3
figure 3

Methodological quality assessment of quasi-experimental studies using JBI

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Results

Study characteristics

As shown in Table 1, a total of 495 patients with cancer undergoing chemotherapy participated in ten studies [1, 3, 9, 13,14,15,16,17,18,19]. Among the participants, 87.21% were female and 63.43% of them were in the intervention group. The mean age of the participants was 53.93 (SD = 10.40). Of the participants, 42.72% had breast cancer. Four studies [9, 13, 15, 16] had an RCT design, and six studies [1, 3, 14, 17,18,19] had a quasi-experimental design. Seven studies [1, 13,14,15, 17,18,19] reported the study’s duration, with a mean of 13.43 months. Seven studies [3, 9, 13, 14, 16, 18, 19] also reported on the length of the intervention. In addition, five studies [1, 9, 13, 15, 19] had a follow-up. Also, six studies [9, 13,14,15,16,17] had a control group.

Table 1 Basic characteristics of the included studies in this systematic review
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Methodological quality assessment of eligible studies

All of the qualifying studies [1, 3, 9, 13,14,15,16,17,18,19] had a “good” quality, as shown in Table 1 and Figs. 1 and 2.

The effect of different art therapy methods on cancer patients undergoing chemotherapy

As shown in Table 1, among all the studies [1, 3, 9, 13,14,15,16,17,18,19] in this systematic review, six studies [1, 13,14,15,16,17] investigated the effect of different art therapy methods on depression, which in five studies [1, 13,14,15, 17] reduced depression in cancer patients undergoing chemotherapy. Six studies [1, 13,14,15,16,17] investigated the effect of different art therapy methods on the anxiety of patients, which in four studies [1, 13, 15, 17] reduced their anxiety. Also, three studies [1, 9, 19] investigated the effect of different art therapy methods on patients’ distress, which in two studies [1, 19] reduced their distress. Also, four studies [3, 16,17,18] investigated the effect of different art therapy methods on the QOL of patients, which improved their QOL in two studies [16, 17].

The characteristics of the art therapy intervention in the included studies are presented in Table 2.

Table 2 Interventions of the studies are included in the systematic review and meta-analysis
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Discussion

Main findings

In this systematic review, we found some positive effects of art-making on depression, anxiety, QoL, and psychological distress in cancer patients on chemotherapy. respectively, Five out of 6 studies showed the positive effect of art therapy on depression. Four out of 6 studies showed a positive effect on anxiety, two out of 3 studies showed a positive effect on mental distress, and two out of 4 studies showed a positive effect of art therapy on the quality of life of patients. In sum, seven out of eleven included studies described these beneficial effects. All studies reported that participants considered the experience valuable to their well-being.

Interpretations

These results partially confirm the result of a recent systematic review study [4] about the effect of art therapy on anxiety, depression, and quality of life in cancer patients. However, because the present study specifically examines cancer patients undergoing chemotherapy, some differences were observed. For example, the quality of life increased in 2 of the 4 present studies. This was even though in the previous study, in 4 out of 6 studies, art therapy increased the quality of life [4]. This difference can be due to the difference in the characteristics of the studied samples. However, the results of art therapy in improving psychological outcomes in patients undergoing chemotherapy are encouraging. Even though the quality of life in cancer patients is of particular importance, psychological needs in cancer patients undergoing chemotherapy are usually unrecognized and undertreated.

Strengths and limitations

Strengths

In this review, we searched PubMed/MEDLINE, Scopus Web of Science, PsycINFO, and EMBASE, which gave us a general review of the available literature, in which all relevant articles were included in the study. Also, the dispersion of studies from all over the world increased the generalizability of the present study.

Limitations

The present study has several limitations. Four studies did not have a control group and 5 were not RCT. Non-randomization can lead to bias in the selection of samples. On the other hand, the studies did not address confounding factors such as the type of cancer and its stage. In addition, there was an imbalance between male and female participants, such that there were no male patients in three studies. Also, one of the limitations was the impossibility of meta-analysis. Considering that the measurement tools are heterogeneous and the interventions were also different. Therefore, meta-analysis was not possible in this study. In sum, it is suggested that the results of the present study should be interpreted with caution.

Clinical implications and future research

Our findings emphasize the importance and application of art therapy in improving the psychological status of cancer patients undergoing chemotherapy. However, it is not-so-high impact on the quality of life can indicate that if art therapy is accompanied by another intervention, it may improve the quality of life of patients. So, it is suggested that RCT studies with a larger sample size be done to prove the effectiveness of art therapy.

Conclusion

Art therapy had positive effects on depression, anxiety, quality of life, and psychological distress of cancer patients undergoing chemotherapy. Meanwhile, the results of studies on the quality of life were contradictory. Research on art therapy in cancer patients on chemotherapy is insufficient. We cannot conclude that art therapy benefits cancer patients on chemotherapy. More rigorous research is needed.