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Effects of Music Therapy on Anesthesia Requirements and Anxiety in Women Undergoing Ambulatory Breast Surgery for Cancer Diagnosis and Treatment: A Randomized Controlled Trial
GENERAL ISSUES IN BREAST CANCER Effects of Music Therapy on Anesthesia Requirements and Anxiety in Women Undergoing Ambulatory Breast Surgery for Cancer Diagnosis and Treatment: A Randomized Controlled Trial Palmer JB, Lane D, Mayo D, et al (Univ Hosps Case Med Ctr, Cleveland, OH; et al) J Clin Oncol 33:3162-3168, 2015
Purpose.dTo investigate the effect of live and recorded perioperative music therapy on anesthesia requirements, anxiety levels, recovery time, and patient satisfaction in women experiencing surgery for diagnosis or treatment of breast cancer. Patients and Methods.dBetween 2012 and 2014, 207 female patients undergoing surgery for potential or known breast cancer were randomly assigned to receive either patientselected live music (LM) preoperatively with therapist-selected recorded music intraoperatively (n ¼ 69), patientselected recorded music (RM) preoperatively with therapist-selected recorded music intraoperatively (n ¼ 70), or usual care (UC) preoperatively with noise-blocking earmuffs intraoperatively (n ¼ 68). Results.dThe LM and the RM groups did not differ significantly from the UC group in the amount of propofol required to reach moderate sedation. Compared with the UC group, both the LM and the RM groups had greater reductions (P < .001) in anxiety scores preoperatively (mean changes [and standard deviation: 30.9 [36.3], 26.8 [29.3], and 0.0 [22.7]), respec-
tively. The LM and RM groups did not differ from the UC group with respect to recovery time; however, the LM group had a shorter recovery time compared with the RM group (a difference of 12.4 minutes; 95% CI, 2.2 to 22.5; P ¼.018). Satisfaction scores for the LM and RM groups did not differ from those of the UC group. Conclusion.dIncluding music therapy as a complementary modality with cancer surgery may help manage preoperative anxiety in a way that is safe, effective, time-efficient, and enjoyable. Music has occupied a surprisingly important position in the course of human history, not only as an art but also as a medium for healing.1 Recently, there has been growing interest from the medical research community in trying to understand scientifically how music affects patients, relatives of patients, and healthcare providers.2-4 Despite this growing interest from practitioners in understanding and incorporating music in evidence-based, modern clinical care, the amount of well-conducted, high-quality studies remains limited. Some of the difficulties of studying music as a medium are its comparatively small effect; the heterogeneity of response to music intervention; the dearth of understanding of personal musical preference; the small number of providers with a combined background in music, medicine, and trial design/ execution; and the lack of psychometric tests that allow for standardized readout of music interventions.5 In light of these challenges, we congratulate Palmer and colleagues for their indepth attempt to shed light on the effects
of live and recorded perioperative music therapy on anesthesia requirements, anxiety levels, recovery time, and patient satisfaction in women undergoing surgery for the diagnosis or treatment of breast cancer. The trial showed that in a relatively large number of patients who underwent a personalized music therapy experience compared with usual clinical care, music therapy can help manage anxiety. Like our research in critically ill patients, the authors found that music can reduce anxiety levels, and time to discharge.6 While the rigor of the study design sets this trial apart from some previously published work, some study limitations exist that challenge a conclusive understanding of music therapy for breast cancer patients undergoing operative intervention. First, despite randomization, a significantly higher number of patients had a lumpectomy in the UC group, whereas the lesser procedure of a biopsy was more frequently performed in the LM group. Second, no blinding occurred, and the 2 most important readout parameters (propofol administration and discharge time) were subject to experimenter bias. A consideration could have been predefined criteria for administering propofol or discharging the patient. The control UC group required more propofol than did either of the study groups, but this difference was not statistically significant. All patients received the same doses of midazolam (an anxiolytic) and fentanyl (a narcotic). Because these medications were given on a weight-related basis, body mass in the three groups should have been
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taken into consideration. If the music therapy was effective in reducing anxiety, perhaps there might have been a difference in the need for an anxiolytic between the study and control groups. Regarding the nonexperimenter dependent variabledthe Global Anxiety-Visual Analog Scale scoredthe standard deviations in each group approached the actual values of the score. Also, the highest baseline anxiety scores were recorded in the LM group, which allows for more ready anxiety reduction to a lower level. The research on the effect of music on stress levels can be very challenging. The authors elegantly circumvented some of the challenges associated with personal musical preference by performing an individualized music intervention. The authors might want to consider analyzing whether there was a common denominator in the chosen music that might simplify selecting music for patients in future interventions.7 In addition, since music has been shown to decrease anxiety with an associated decrease in medications in other prospective randomized controlled trials,8,9 a study design might be considered where the anxiolytic medication could be titrated according to the objectively measured change in a patient’s anxiety level after the anxiolytic effect of the music in the holding area. Also, the use of noisereducing headphones during the
116
operative procedure is not routine. Perhaps it would be more relevant to standard practice to not have headphones in the control group.10 We think that the authors’ approach of having a live and interactive music therapy intervention as part of a well-conducted trial sets a new standard for studying the effects of music in health care. The patient populations of women and men with breast cancer are particularly important groups to study since high anxiety levels in these patients have been reported. We are looking forward to further high-quality research from this group on the effects of music on breast cancer patients. C. Conrad, MD, PhD T. Rahlfs, MD
References 1. Conrad C. Music for healing: from magic to medicine. Lancet. 2010; 376:1980-1981. 2. Tilt AC, Werner PD, Brown DF, et al. Low degree of formal education and musical experience predict degree of music-induced stress reduction in relatives and friends of patients: a single-center, randomized controlled trial. Ann Surg. 2013;257:834-838. 3. Conrad C, Konuk Y, Werner PD, et al. A quality improvement study on avoidable stressors and countermeasures affecting surgical
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 2 2016
motor performance and learning. Ann Surg. 2012;255:1190-1194. 4. Conrad C, Konuk Y, Werner P, et al. The effect of defined auditory conditions versus mental loading on the laparoscopic motor skill performance of experts. Surg Endosc. 2010;24:1347-1352. 5. Nelson A, Hartl W, Jauch KW, et al. The impact of music on hypermetabolism in critical illness. Curr Opin Clin Nutr Metab Care. 2008;11:790-794. 6. Conrad C, Niess H, Jauch KW, Bruns CJ, Hartl W, Welker L. Overture for growth hormone: requiem for interleukin-6? Crit Care Med. 2007;35:2709-2713. 7. Conrad C. Esoteric or exoteric? Music in medicine. Medscape J Med. 2008;10:20. 8. Koch ME, Kain ZN, Ayoub C, Rosenbaum SH. The sedative and analgesic sparing effect of music. Anesthesiology. 1998;89: 300-306. 9. Wang SM, Kulkarni L, Dolev J, Kain ZN. Music and preoperative anxiety: a randomized, controlled study. Anesth Analg. 2002;94: 1489-1494. 10. Yamasaki A, Mise Y, Mise Y, et al. Musical preference correlates closely to professional roles and specialties in operating room: a multicenter cross-sectional cohort study with 672 participants. Surgery. 2016;159: 1260-1268.
Purpose.dTo investigate the effect of live and recorded perioperative music therapy on anesthesia requirements, anxiety levels, recovery time, and patient satisfaction in women experiencing surgery for diagnosis or treatment of breast cancer. Patients and Methods.dBetween 2012 and 2014, 207 female patients undergoing surgery for potential or known breast cancer were randomly assigned to receive either patientselected live music (LM) preoperatively with therapist-selected recorded music intraoperatively (n ¼ 69), patientselected recorded music (RM) preoperatively with therapist-selected recorded music intraoperatively (n ¼ 70), or usual care (UC) preoperatively with noise-blocking earmuffs intraoperatively (n ¼ 68). Results.dThe LM and the RM groups did not differ significantly from the UC group in the amount of propofol required to reach moderate sedation. Compared with the UC group, both the LM and the RM groups had greater reductions (P < .001) in anxiety scores preoperatively (mean changes [and standard deviation: 30.9 [36.3], 26.8 [29.3], and 0.0 [22.7]), respec-
tively. The LM and RM groups did not differ from the UC group with respect to recovery time; however, the LM group had a shorter recovery time compared with the RM group (a difference of 12.4 minutes; 95% CI, 2.2 to 22.5; P ¼.018). Satisfaction scores for the LM and RM groups did not differ from those of the UC group. Conclusion.dIncluding music therapy as a complementary modality with cancer surgery may help manage preoperative anxiety in a way that is safe, effective, time-efficient, and enjoyable. Music has occupied a surprisingly important position in the course of human history, not only as an art but also as a medium for healing.1 Recently, there has been growing interest from the medical research community in trying to understand scientifically how music affects patients, relatives of patients, and healthcare providers.2-4 Despite this growing interest from practitioners in understanding and incorporating music in evidence-based, modern clinical care, the amount of well-conducted, high-quality studies remains limited. Some of the difficulties of studying music as a medium are its comparatively small effect; the heterogeneity of response to music intervention; the dearth of understanding of personal musical preference; the small number of providers with a combined background in music, medicine, and trial design/ execution; and the lack of psychometric tests that allow for standardized readout of music interventions.5 In light of these challenges, we congratulate Palmer and colleagues for their indepth attempt to shed light on the effects
of live and recorded perioperative music therapy on anesthesia requirements, anxiety levels, recovery time, and patient satisfaction in women undergoing surgery for the diagnosis or treatment of breast cancer. The trial showed that in a relatively large number of patients who underwent a personalized music therapy experience compared with usual clinical care, music therapy can help manage anxiety. Like our research in critically ill patients, the authors found that music can reduce anxiety levels, and time to discharge.6 While the rigor of the study design sets this trial apart from some previously published work, some study limitations exist that challenge a conclusive understanding of music therapy for breast cancer patients undergoing operative intervention. First, despite randomization, a significantly higher number of patients had a lumpectomy in the UC group, whereas the lesser procedure of a biopsy was more frequently performed in the LM group. Second, no blinding occurred, and the 2 most important readout parameters (propofol administration and discharge time) were subject to experimenter bias. A consideration could have been predefined criteria for administering propofol or discharging the patient. The control UC group required more propofol than did either of the study groups, but this difference was not statistically significant. All patients received the same doses of midazolam (an anxiolytic) and fentanyl (a narcotic). Because these medications were given on a weight-related basis, body mass in the three groups should have been
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 2 2016
115
taken into consideration. If the music therapy was effective in reducing anxiety, perhaps there might have been a difference in the need for an anxiolytic between the study and control groups. Regarding the nonexperimenter dependent variabledthe Global Anxiety-Visual Analog Scale scoredthe standard deviations in each group approached the actual values of the score. Also, the highest baseline anxiety scores were recorded in the LM group, which allows for more ready anxiety reduction to a lower level. The research on the effect of music on stress levels can be very challenging. The authors elegantly circumvented some of the challenges associated with personal musical preference by performing an individualized music intervention. The authors might want to consider analyzing whether there was a common denominator in the chosen music that might simplify selecting music for patients in future interventions.7 In addition, since music has been shown to decrease anxiety with an associated decrease in medications in other prospective randomized controlled trials,8,9 a study design might be considered where the anxiolytic medication could be titrated according to the objectively measured change in a patient’s anxiety level after the anxiolytic effect of the music in the holding area. Also, the use of noisereducing headphones during the
116
operative procedure is not routine. Perhaps it would be more relevant to standard practice to not have headphones in the control group.10 We think that the authors’ approach of having a live and interactive music therapy intervention as part of a well-conducted trial sets a new standard for studying the effects of music in health care. The patient populations of women and men with breast cancer are particularly important groups to study since high anxiety levels in these patients have been reported. We are looking forward to further high-quality research from this group on the effects of music on breast cancer patients. C. Conrad, MD, PhD T. Rahlfs, MD
References 1. Conrad C. Music for healing: from magic to medicine. Lancet. 2010; 376:1980-1981. 2. Tilt AC, Werner PD, Brown DF, et al. Low degree of formal education and musical experience predict degree of music-induced stress reduction in relatives and friends of patients: a single-center, randomized controlled trial. Ann Surg. 2013;257:834-838. 3. Conrad C, Konuk Y, Werner PD, et al. A quality improvement study on avoidable stressors and countermeasures affecting surgical
Breast Diseases: A Year BookÒ Quarterly Vol 27 No 2 2016
motor performance and learning. Ann Surg. 2012;255:1190-1194. 4. Conrad C, Konuk Y, Werner P, et al. The effect of defined auditory conditions versus mental loading on the laparoscopic motor skill performance of experts. Surg Endosc. 2010;24:1347-1352. 5. Nelson A, Hartl W, Jauch KW, et al. The impact of music on hypermetabolism in critical illness. Curr Opin Clin Nutr Metab Care. 2008;11:790-794. 6. Conrad C, Niess H, Jauch KW, Bruns CJ, Hartl W, Welker L. Overture for growth hormone: requiem for interleukin-6? Crit Care Med. 2007;35:2709-2713. 7. Conrad C. Esoteric or exoteric? Music in medicine. Medscape J Med. 2008;10:20. 8. Koch ME, Kain ZN, Ayoub C, Rosenbaum SH. The sedative and analgesic sparing effect of music. Anesthesiology. 1998;89: 300-306. 9. Wang SM, Kulkarni L, Dolev J, Kain ZN. Music and preoperative anxiety: a randomized, controlled study. Anesth Analg. 2002;94: 1489-1494. 10. Yamasaki A, Mise Y, Mise Y, et al. Musical preference correlates closely to professional roles and specialties in operating room: a multicenter cross-sectional cohort study with 672 participants. Surgery. 2016;159: 1260-1268.