Coloring beyond the cancer ward: A randomized controlled pilot trial of short-term visual art therapy for chemotherapy-related distress

Article ID: 5436

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Keywords: breast cancer; mandala coloring; visual art therapy; psychological distress; randomized controlled trial

Abstract

Breast-cancer treatment often disrupts appearance and identity, leaving roughly one-third of patients in clinically significant distress. This dual-center pilot RCT assessed whether a brief, low-cost mandala-coloring program could alleviate chemotherapy-related distress in women with early-stage breast cancer. Fifty post-surgical patients starting adjuvant chemotherapy were randomized 1:1 to either three 45-minute chair-side coloring sessions delivered over three weeks or an active control involving neutral reading for the same duration; both groups received standard care. Distress (NCCN Distress Thermometer [DT] 0-10) was the primary outcome, with anxiety and depression (HADS-A/D), fatigue (BFI), and global quality of life (EORTC QLQ-C30) as secondary endpoints, all measured at baseline and one week after the final session. Feasibility targets were surpassed: 86% of approached patients enrolled, 96% completed follow-up, and 92% of intervention participants attended every session. Adjusted analyses showed lower postintervention distress in the art-therapy group (mean = 3.4) versus controls (mean = 5.1), giving a −1.7-point difference (p = 0.02, Cohen’s d = 0.85); only 28% of intervention patients, compared with 80% of controls, remained above the DT clinical cut-off (≥4). Anxiety dropped markedly in the coloring arm (8.70 to 6.20) but increased in controls (8.40 to 9.60), producing a −3.3-point adjusted difference (p < 0.001, d ≈ 1.2). Depression and fatigue showed no significant between-group differences, and global quality of life declined in controls but was largely maintained in the art group, although this trend did not reach significance. Structural-equation modelling (χ² = 7.11, CFI = 0.995, RMSEA = 0.036) confirmed a latent “distress” factor defined by DT, HADS-A, and HADS-D; the intervention exerted a significant negative effect on this factor (β = −0.55, p = 0.006), driven chiefly by anxiety reduction, with no direct paths to fatigue or quality of life. In summary, three short mandala-coloring sessions are feasible during chemotherapy and substantially reduce overall distress and anxiety, though depressive symptoms, fatigue, and broad quality-of-life indices were unchanged over this brief interval. Larger, longer trials should verify durability, explore body-image mechanisms, and determine how best to integrate chair-side coloring into routine psycho-oncology practice.