ABSTRACT Approximately one-third of women coping with breast cancer experience persistent symptoms of depression, pain and fatigue, which are not normative and are difficult to treat. Emotion approach coping, including awareness, acceptance and expression of emotions is related to more rapid resolution of depressive symptoms and improved health outcomes in breast cancer survivors. Since expression of emotion is inconsistent with social norms in some ethnic minorities, specifically those from a more traditional background, BC survivors from these ethno-cultural minorities are less likely to seek opportunities for emotional expression and support. Art Therapy is a form of psychotherapy that uses visual art-making as a form of expression and communication within a safe and supportive relationship, in a therapeutic setting. Art Therapy is documented in cancer settings to alleviate psychological symptoms and to reduce physical complaints. BC survivors have reported that art-making increased access to emotional content and its expression. Because Art Therapy provides the opportunity for indirect expression, it may be particularly potent with individuals from traditional and collectivist ethno-cultures. The purpose of this study is to examine emotional processing and cholinergic anti- inflammatory processes through which an AT intervention may reduce depression, pain and fatigue. To examine these emotional processing and cholinergic anti-inflammatory mechanisms, we have designed a randomized controlled study with careful controls. Responsive to PAR-14-294 on Arts-Based Approaches in Palliative Care for Symptom management, the research seeks to accomplish: AIM 1: To examine two mechanisms: 1) emotional processing and 2) cholinergic anti-inflammatory processes, through which Art Therapy reduces depression, pain and fatigue in Jewish and Arab BC survivors. Hypothesis: Participants in Art Therapy (vs sham Art Therapy (Mandala)) will experience greater increases in emotion processing (awareness, acceptance and expression), resting HRV, and regulatory cytokine expression as well as a greater decrease in pro-inflammatory cytokine expression: which in turn will mediate the effect of Art Therapy on depression, pain and fatigue. AIM 2: To examine ethno-cultural differences in the effect of Art Therapy in women from a traditional collectivist ethno-cultural background, compared to women from a more individualist western ethno-cultural background. Hypothesis: Individuals from a traditional collectivist ethno-cultural group will demonstrate a more prominent response to the Art Therapy intervention, compared to women in the more individualist western ethno-cultural group, beyond differences in traditional values. We will conduct a randomized controlled trial of 120 Jewish and 120 Arab women diagnosed with breast cancer diagnosed within the last year, recruited in Israel and randomized to undergo an 8-week program of AT compared to sham Art Therapy.

NARRATIVE Over 200,000 women are diagnosed with breast cancer in the United States annually. Many breast cancer patients and survivors cope with a fused conglomerate of depression, pain and fatigue that affect quality of life; are very difficult to treat and are associated with poor adherence to cancer treatments, delayed return to work, and higher healthcare use, costs, and hospitalizations. Art Therapy provides an alternative to verbal Psychotherapy and understanding the mechanisms through which its salutary effects are gained will promote its standard application in palliative care settings.