Art therapy in cancer patients can be studied from a psychophysiological perspective as a complementary intervention for stress management, emotion regulation, and psychological adjustment support. Cancer diagnosis, long-term treatments, pain, uncertainty about the future, and physical changes can cause repeated activation of stress response systems. One of the most important of these systems is the hypothalamic-pituitary-adrenal axis, which plays a role in regulating the body's response to stress through the interaction between the hypothalamus, pituitary gland, and adrenal cortex. The activation of this axis is associated with an increase in the release of hormones such as cortisol, and in conditions of chronic stress, a change in its normal pattern of activity can be associated with psychological and physical consequences.
From a theoretical perspective, art therapy can help reduce emotional arousal and increase a sense of control by creating a safe, structured, and controllable environment. Activities such as painting, drawing, music, collage, and creative writing make it possible to express difficult experiences without the need for direct verbal explanation. The process of creating a work of art can shift the patient's attention from worry, rumination, and perceived threat to a purposeful activity, and provide the ground for reducing psychological stress by enhancing emotion regulation, relaxation, and a sense of agency.
Chronic activity of the hypothalamic–pituitary–adrenal axis can be associated with sleep disturbances, fatigue, anxiety, mood changes, and decreased quality of life, which are of particular importance in patients with cancer. Art therapy by targeting the psychological factors affecting stress can moderate part of the cycle between stress, physiological arousal, and psychological distress. Possible mechanisms of this effect include decreasing constant attention to threats, increasing calmness, strengthening emotion regulation, and creating a positive experience of active participation in the treatment process.
Research evidence on art interventions in patients with cancer has shown that art and music-based activities can be associated with a reduction in some indicators of anxiety, depression, distress and stress, as well as improved quality of life. Some psychophysiological studies have also shown that artistic activities and aesthetic experiences can influence markers associated with arousal and stress response. However, direct evidence on how and to what extent art therapy alters the hypothalamic–pituitary–adrenal axis in patients with cancer is still limited, and more rigorous studies are needed to draw firm conclusions.
Measurements of salivary cortisol, heart rate, heart rate variability, blood pressure, and stress self-report indices can be used in future research to investigate the relationship between art therapy and psychophysiological regulation. Combining these indicators with standard tools for measuring distress, anxiety, depression, sleep quality, and quality of life can provide a more accurate picture of possible intervention mechanisms. Simultaneous review of biological and psychological indicators will allow for a better separation of the direct and indirect effects of art therapy.
In terms of clinical application, art therapy can be used during the course of diagnosis, chemotherapy, radiation therapy, surgery, rehabilitation, and palliative care as part of psychosocial care. Short-term art activity while waiting or receiving treatment can help reduce tension and create a sense of calm, and more regular interventions can focus on expressing emotion, adjusting to illness, and strengthening coping resources. The choice of type of activity should be made based on the patient's physical ability, preferences, cognitive condition, and mental state.
One of the important uses of art therapy is to help turn ambiguous stress and difficult experiences into visible and conversationable content. The patient may not be able to express the fear of progressing the disease, the fear of death, the change in body image, or the feeling of lack of control. Images, colors, music, or writing can act as a medium for the expression of these experiences, allowing for their gradual processing. Such a process may help reduce emotional avoidance and increase a sense of psychological cohesion.
Despite the theoretical and clinical capacities, there are some important limitations. The hypothalamic–pituitary–adrenal axis response is not only affected by psychological stress, and factors such as type of cancer, medications, pain, sleep disturbance, inflammation, nutrition, sampling time, and physical condition can affect hormonal indicators. Therefore, cortisol changes cannot be considered as a definitive indicator of the effectiveness of art therapy alone. Also, the wide variation in the type, duration, and intensity of art interventions makes it difficult to compare the results of the studies.
Another challenge is the gap between psychological evidence and direct neuroendocrine evidence. Reducing anxiety or distress after an art intervention does not necessarily mean a direct change in the hypothalamic–pituitary–adrenal axis, and may involve mediating pathways such as improved sleep, reduced rumination, increased social support, or altered perception of pain. Therefore, interpretation of the results should avoid simply attributing any psychological change to a specific hormonal mechanism.
Future research should investigate cortisol changes at several points in time with longitudinal designs and controlled trials and combine it with psychological and physiological indicators. Comparing different types of artistic activities, examining the differences in patients' responses at different stages of treatment, and using standard protocols can increase the validity of the evidence. Also, investigating the role of characteristics such as emotion regulation, self-efficacy, resilience, and meaning-making will help to understand the psychological pathways affecting stress regulation. Based on the available evidence, art therapy can be considered as a complementary and potentially useful approach for reducing distress and supporting psychophysiological regulation in patients with cancer, but attributing its direct and definitive effect on the hypothalamic–pituitary–adrenal axis still requires stronger empirical evidence.