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Music therapy and radiation oncology: State of art and future directions
Complementary Therapies in Clinical Practice 39 (2020) 101124
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Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Music therapy and radiation oncology: State of art and future directions Valerio Nardone a, *, Claudia Vinciguerra b, Pierpaolo Correale c, Cesare Guida a, Paolo Tini d, e, Alfonso Reginelli f, Salvatore Cappabianca f a
Unit of Radiation Oncology, Ospedale Del Mare, Naples, Italy Department of Neurology, A.O.U. San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy c Unit of Medical Oncology, Grand Metropolitan Hospital “Bianchi Melacrino Morelli” Reggio Calabria, Italy d Unit of Radiation Oncology, University Hospital of Siena, Italy e Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA f Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy b
A B S T R A C T
Background: Effectiveness of music-based interventions (Music therapy, MT) on cancer patients’ is a current research theme. Oncology patients may respond to radiation treatment (RT) with anxiety expressed as stress, fear, depression, and frustration. Objectives: The aim of this review is to discuss the effectiveness of MT in patients undergoing RT. Data sources: All English medical papers registered in the Web of Knowledge, PubMed, Google Scholar and ScienceDirect from March 1999 to March 2019. Inclusion and exclusion criteria: We selected all the articles concerning the use of MT in pre-RT anxiety and distress during RT treatment. Results: Out of 1184 articles selected, 132 abstracts were analyzed and 13 papers were finally evaluated for the current analysis, for a total of 946 participants. Discussion: We investigated the role and the efficacy of MT for patients receiving RT and the future challenges in the clinical management of oncology patients before and during radiotherapy.
1. Introduction Cancer diagnosis often implies extensive emotional, physical and social suffering, therefore current cancer management incorporates different psychosocial interventions in order to improve patients’ qual ity of life [1,2]. The psychological distress related to the diagnosis can be devastating for the patients and their friends and family [3]. With responses that include denial of the diagnosis, fear of death fear of recurrence of the cancer concerns about body image, the impact on sexuality, the impact on relationships, and lifestyle [4,5]. Conversely, the illness itself or the cancer treatments may lead to a radical modification of patients’ activities of daily living, especially in cases of advanced illness [6]. These conditions can have a relevant impact on patients’ quality of life [7], and eventually induce elevated levels of psychological distress, anxiety and depression [8–11]. Appropriate Psychosocial interventions are needed ranging from educational interventions to intensive counselling and integrative can cer therapies. Previous studies on advanced cancer patients treated with palliative care proved that psychosocial care (e.g. psychological, social, informational, communication, and spiritual support) constitutes a large
proportion of patients’ needs [12,13]. Amongst these interventions, music therapy (MT) is recognized as an effective treatment in cancer patients leading to a general improvement of patients’ quality of life, as it has been shown to be directly correlated with beneficial effects on anxiety, pain, fatigue, heart rate, respiratory rate and blood pressure in this population [8,14–18]. Music therapy and music medicine are now widely used as nonpharmacological interventions in different clinical and therapeutic set tings [19–22]. In the last ten years, a large number of studies conducted in people undergoing different cancer therapies for different oncological diseases, have evaluated the potential effects of music therapy (MT) employed to alleviate symptoms and treatment side effects [23–31]. Radiation therapy (RT) is one of the treatments used in cancer, and may induce important stress and anxiety in cancer patients, mainly due to the fear of RT, lack of information about treatment and side effects [32–36]. Nevertheless the role of MT for patients receiving RT is not well described, as only five studies out of fifty-two in the last Cochrane Re view of Bradt [15] dealt with MT in RT cancer patients.
* Corresponding author. Radiation Oncology Unit, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy. E-mail address: [email protected] (V. Nardone). https://doi.org/10.1016/j.ctcp.2020.101124 Received 12 December 2019; Received in revised form 11 February 2020; Accepted 22 February 2020 Available online 27 February 2020 1744-3881/© 2020 Elsevier Ltd. All rights reserved.
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2. Methods
Table 1 PICO definition of linclusion criteria.
With this review we sought to address the effectiveness of MT for cancer patients undergoing RT. Improving our knowledge regarding this approach in cancer patients may provide support for exploring these interventions in clinical practice. This systematic review complies with the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [37] (see Fig. 1). Study design and criteria for exclusion/inclusion. We adopted the PICO approach to include studies (population, intervention, comparison, outcomes, study type – see Table 1). We reviewed abstract of retrieved papers:
PICO
Inclusion criteria
Population Intervention Comparison Outcomes
Radiation therapy patients Use of Music Therapy interventions With or without control groups Symptomatology (anxiety, distress, depression, pain); Physiological indices (heart rate, blood pressure, respiratory rate); Any
Study type
2.2. Data extraction and analysis Data extraction by all the authors was divided into study, partici pants and intervention characteristics, comparators, outcomes, results and limitations. The data was discussed and any discrepancies were resolved prior to final analysis. The heterogeneity amongst the different studies in terms of outcomes and assessment tools did not enable a metaanalysis of the studies to be undertaken therefore a descriptive analysis was performed.
1) Sample including patients undergoing RT; 2) There was an intervention of MT; 3) The intervention addressed the psychosocial distress of patients un dergoing RT. A comparator was intentionally not specified to ensure a comprehensive investigation of MT without limiting its comparison to a specific alternative intervention; 4) There was an evaluation of the interventions adopted;
3. Results Each researcher individually searched the database then the initial search results were merged and duplicate results removed. After 540 duplicates were removed, 1184 titles were screened for eligibility. Each researcher independently assessed 132 eligible ab stracts. Studies were excluded following the fore-mentioned inclusion criteria and PICO strategy. Discrepancies were resolved on a case-bycase basis by discussion. Through this procedure, 13 original articles were identified for inclusion in the final review. Full text copies of the articles were obtained, and results and out comes were extracted in order to tabulate the details of the selected articles. Each relevant article was scored using the quality rating adopted by Keim-Malpass, Letzkis and Kennedy [38] (see Table 2) and the Robb’s music-based reporting guidelines [39] (see Table 3). Fig. 1 represents the process of screening and selection of the articles, in order to obtain the final 13 articles for review, which consist of 13 studies for a total of 946 participants.
If these criteria were met, papers were obtained and reviewed in full. Exclusion criteria were: intervention addressed patients undergoing chemotherapy, surgery or other form of radiation (i.e.: diagnostic im aging). Grey literature, including conference lectures, case reports, commentary papers. Reviews and systematic reviews were at the same time excluded. 2.1. Search strategy The systematic review was conducted by searching all English medical papers registered in the web of Knowledge, PubMed, Google Scholar, Science Direct, Embase and Cochrane Library from 1991 to 2019. The search strategy was “music therapy and radiotherapy” or “radiation and music”. We also took into account the references of other reviews, as well as those of the selected articles, to include other papers. Two reviewers (VN and CV) independently appraised the eligible studies with any disputes resolved collaboratively after discussion.
3.1. Participants’ characteristics and interventions used The sample population ranged from 11 to 200 participants and all the selected studies were single-site studies. The interventions used were Table 2 Summary of quality scoring criteria. Rating number (design)
Details
LEVEL I LEVEL II LEVEL III LEVEL IV Rating rank (quality) A-HIGH
Randomized control trial (RCT) Quasi-experimental trial Non experimental trial Qualitative Details
B-GOOD
Fig. 1. Workflow of the systematic review process, according to the guidelines for Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA).
C-LOW
2
Consistent, generalizable results, sufficient sample size, adequate control, definitive conclusions, consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence Reasonably consistent results, sufficient sample size for the study design, some control, fairly definitive conclusions, reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence Little evidence with inconsistent results, insufficient sample size for the study design, conclusions cannot be drawn
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Complementary Therapies in Clinical Practice 39 (2020) 101124
Rossetti A et al. [43] also evaluated the impact of MT on anxiety and distress in patients with newly diagnosed head and neck or breast can cer. The intervention was a music listening session with a trained music therapist before simulation CT, and the measure of outcomes included pre-State-Trait Anxiety Inventory (STAI-S Anxiety) questionnaire and Symptom Distress Thermometer (SDT). The results showed that the MT significantly lowered patient anxiety and distress during the clinical procedure. ^ntara-Silva et al. [42] in their randomized controlled trial Alca investigated the influence of MT on the reduction of fatigue in women with breast or gynecological malignancies under radiotherapy. 30–40 min individual sessions of music therapy with a trained music therapist were offered to participants of the experimental arm, and the Authors analyzed fatigue and depression. On the basis of the reduction of both outcomes in the experimental arm, the Authors concluded that indi vidual MT sessions are effective to reduce fatigue related to cancer and symptoms of depression as well as to improve quality of life for the specific population.
Table 3 Music-Based Intervention Guidelines reporting by Robb’s et al. Music based interventions components reccomended
Details
4 A Intervention Theory
To Provide a rationale for the music selected, specifying how qualities and delivery of the music are expected to impact targeted outcomes. To Provide precise details of the music intervention and, when applicable, descriptions of procedures for tailoring interventions to individual participants To specify who preselect the music (investigator, participant selected from limited set, participant selected from own collection, or tailored based on patient assessment). To provide reference for sheet music or sound recording (when using published music) To specify who delivered the live music and the size of the performance group (e.g., interventionist only, interventionist and participant). Specify music and/or non-music materials. Describe music-based intervention strategies under investigation (examples: music listening, songwriting, improvisation, lyric analysis, rhythmic auditory stimulation, etc) To report number of sessions, session duration, and session frequency including practice sessions Specify interventionist qualifications and credentials. Specify how many interventionists delivered study conditions. Describe strategies used to ensure that treatment and/or control conditions were delivered as intended (e.g., interventionist training, manualized protocols, and intervention monitoring) Describe where the intervention was delivered; include location, privacy level, and ambient sound. Specify whether interventions were delivered to individuals or groups of individuals, including the size of the group
4 B Intervention Content
4 B1 Music selection.
4 B2 Music sources details 4 B3 Music Delivery Method (Live or Recorded). 4 B4 Intervention Materials 4 B5 Intervention Strategies.
4C Intervention Delivery Schedule 4D Interventionist. 4E Fidelity Strategies for Treatment Delivery
4F Setting. 4G Unit of Delivery.
3.3. Relaxation techniques including music In 2001 (CIT). Elith et al. [46] produced one of the first reports of MT applied to RT patients. They applied different relaxation techniques (MT, aromatherapy and guided imagery) in a small prospective study that included 14 participants. They analyzed anxiety with STAI scale and concluded that each of the adopted techniques could provide clin ical reduction of anxiety. Clark et al. [45] adopted in a RCT self-initiated strategies used to relax, including deep breathing, visual imagery, muscle relaxation. In addition to these strategies, experimental group patients performed two additional activities: music listening and music used to create a visual image, with the guide of a trained music therapist. The Authors analyzed fatigue, pain, anxiety and depression and found that anxiety and distress were significantly lower in the experimental arm and that there was a consistent correlation between number of times music was used and the change in treatment-related distress. Nixon et al. [47] analyzed different strategies to reduce anxiety in patients requiring thermoplastic mask during RT (defined as “mask anxiety”). Such strategies consist into discussions with health pro fessionals, self-taught strategies and music listening. The outcomes included distress thermometer for mask anxiety, and it was found that music listening was helpful in reducing the distress in the case of 72% of participants.
placed into two categories: interventions used before RT and in terventions used during the RT procedure. In adult patients, the outcome measures in the studies differed and included fatigue assessment, anxi ety evaluation, depression evaluation and clinical assessments. The studies involving pediatric patients, used clinical evaluation [40] or specific outcome questionnaires [41]. The interventions were diverse amongst the studies, including ses sions with a trained music therapist [40,42–44], relaxation techniques combined with music [45–47], music listening before or during RT [41, 48–52]. We will briefly describe the different strategies of MT according to the previous classification (see Table 4 for details of the studies included).
3.4. Music listening before and during RT Music listening before and during RT was the most commonly used technique of MT in RT, as this strategy is both simple and efficacious. The first example of music listening during RT was reported in the work of Maureen Smith et al., in 2001 [51], a RCT involving 42 par ticipants. The experimental arm used self-selected music listening dur ing RT and the Authors analyzed anxiety with STAI scale. The results showed that there were no significant differences among the groups, albeit in post-hoc analysis there was a trend suggesting some benefits in MT arm. On the other hand Barry et al. [41] conducted a very small single site RCT involving 11 pediatric patients undergoing RT. They investigated the potential use of a MT compact disc created by the involved children using interactive computer-based music software in turn remixed by the music therapist-researcher. The Authors investigated the patients, par ents and RT professional’s perceptions of distress and efficacy together with the Kidscope questionnaire. Unfortunately, they found no differ ences in outcomes as well as lack of congruence among groups. At the same time, MT was considered enjoyable, supportive and helpful for both patients and families. O’ Callaghan et al. [50] also conducted a RCT with 100 participants.
3.2. MT with trained music therapist O’Callaghan et al. [40] was the first report of MT performed with a music therapist, in a pediatric setting. They placed musical instrument in a dedicated space, and encouraged both patients and families to “play” with a music therapist, thus increasing the means of communication, self-expression and creativity. The outcome measure was the clinical evaluation, and a range of benefits were perceived, such as stress relief, physical and psychosocial improvements, facilitation of the clinical communication. Zhao et al. [44] performed a 30 min specific music intervention before RT in a cohort of 95 patients. The Authors measured anxiety and physiological indices and found that with MT both the outcomes were substantially lower in the experimental arm. 3
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Table 4 Study details. Author, Year, Place
Type
Number of patients
Interventions
Measure of outcomes
Results
Rating Number (design) and Rank (quality)
Robb’s music-based reporting guidelines applied
AlcantaraSilva et al., 2018, Brazil
RCT, single site;
116 patients (63 control arm, 53 sperimental arm);
30–40 min of a music therapy session with a trained music therapist
� FACT-F results were significant regarding Trial Outcome Index (P ¼ .011), FACT-G (P ¼ .005), and FACT-F (P ¼ .001) for the sperimental arm compared with the control arm;
IB
4A 4B1 4C 4D 4F 4G
Barry et al., 2010, Australia
Small RCT, single site
11 participants (5 sperimental arm, 6 control arm);
Music Therapy Compact Disc (CD);
✓ Functional Assessment of Cancer Therapy: Fatigue (FACT-F) version 4; ✓ Functional Assessment of Cancer Therapy–General (FACT-G) version 4; ✓ Beck Depression Inventory; ✓ 3 separate times; ✓ Kidscope questionnaire; ✓ Parental perceptions of the efficacy; ✓ Patient, parents and RT perceptions of distress;
IIC
4A 4B 4B1 4B3 4B5 4D 4G
Chen et al., 2013, Taiwan
RCT study, single site;
200 participants (100 sperimental arm, 100 control arm);
Fifteen-minute music intervention before RT;
✓ State-Trait Anxiety Inventory; ✓ Physiological indicators of anxiety;
IB
4A 4B 4B1 4B3 4B5 4C 4G
Clark et al., 2006, US;
RCT, single site;
63 participants (35 experimental arm, 28 control arm);
✓ Single item distress numeric rating scale or fatigue and pain (NRS); ✓ Hospital Anxiety and Depression Scale (HAD); ✓ Profile of Mood States (POMS) Fatigue;
IIC
4A 4B 4B1 4B3 4B4 4B5 4G
Elith et al., 2001, Australia;
Small prospective study, single site;
14 participants (7 experimental arm, 7 control arm);
✓ State-Trait Anxiety Inventory;
� Clinical reduction in anxiety levels in each of the three relaxation interventions compared to control arm;
IIC
4A 4B 4B4
Karadag et al., 2019, Turkey;
RCT, single site;
60 participants (30 eperimental arm, 30 control arm);
Self-initiated strategies used to relax for all the patients (deep breathing, visual imagery, muscle relaxation and other; experimental group completed two additional items: listened to the mood and flow of the music, and used music to create a visual image, guided by a trained music therapist; Three relaxation intervention techniques (music therapy, aromatherapy, guided imagery); Music listening intervention (classical music);
� No differences in time in treatment room, distress; � Lack of congruence in ratings among groups; � Music therapy was considered fun, supportive and helpful for children and families; � Baseline State/Trait scores and vital signis comparable between groups; � After intervention, statistically significant decrease in State-Trait anxi ety scores and systolic pres sure in experimental arm; � Anxiety and distress were significantly lower for experimental arm than control arm; � Within the experimental arm, there was a significant correlation between number of times music was used and the change in treatmentrelated distress;
� Significant difference in HAD-A (p < 0,001), HAD-D (p < 0,001) and RTCQ scores (p < 0,001);
IIB
4A 4B 4B3 4G
Nixon et al., 2019, Australia;
Prospective study, single site;
35 participants (cohort study);
✓ Hospital Anxiety and Depression Scale (HAD); ✓ Radiation Therapy Comfort Questionnaire (RTCQ); ✓ Distress Thermometer (DT) for mask anxiety;
� Music listening was reported helpful in reducing DT for 72% of the participants;
IIIC
4A 4B 4B5 4G
O0
Descriptive study, single site;
60 participants (cohort study);
✓ Clinical evaluation;
IIIC
RCT, single site;
100 participants (50 experimental arm, 50 control arm);
� A range of benefits were perceived, from temporary respite from stress, to physical and psychosocial improvements; � Clinical communication facilitated; � Anxiety decreased following RT in both arms; � Music group patients were significantly more likely to
4A 4B 4B1 4B3 4D 4F 4G 4A 4B1 4B3 4B5 4G
O0
Callaghan et al., 2007, Australia;
Callaghan et al., 2012, Australia;
Different strategies to reduce anxiety in patients requiring thermoplastic mask during RT (discussions with health professionals, self-taught strategies, music listening); Music therapy (passive and active) in sessions with a trained music therapist;
Self selected music listening during RT;
✓ State-Trait Anxiety Inventory; ✓ Subjective experience;
IC
(continued on next page)
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Complementary Therapies in Clinical Practice 39 (2020) 101124
Table 4 (continued ) Author, Year, Place
Type
Number of patients
Interventions
Measure of outcomes
Rossetti et al., 2017, US;
RCT, single site;
78 participants (39 experimental arm, 39 control arm);
Music session listening with a trained music therapist before simulation CT;
✓ State-Trait Anxiety Inventory; ✓ Symptom Distress Thermometer (SDT);
Smith et al., 2001, US;
RCT, single site;
42 participants (19 experimental arm, 23 control arm);
Self selected music listening during simulation and RT;
✓ State-Trait Anxiety Inventory;
Hanedan Uslu, 2017, Turkey;
Prospective Trial, single site;
72 participants (36 experimental arm, 36 control arm);
Patient tailored music listening during RT;
✓ State-Trait Anxiety Inventory;
Zhao et al., 2008, China;
RCT, single site;
95 participants
30 min of music intervention;
✓ Zung Anxiety scale (SAS); ✓ Hama Anxiety scale (HAMA); ✓ Physiological indices;
Results
want music in future RT sessions (p:0,007); � Benefit of music in terms of feeling supported, distracted; � Music Intervention significantly lowered STAI and SDT scores; � No significant differences between the two groups; � In post-hoc analysis changes and trends suggesting benefit of music therapy; � After RT, significant decrease (p:0,001) of STAI scores in experimental group, and significant increase (p:0,003) in control group; � Physiological indices, SAS and HAMA scores were significantly lower in experimental arm than control group (p < 0,05), as well as before RT and after RT in the experimental arm (p < 0,05);
Rating Number (design) and Rank (quality)
Robb’s music-based reporting guidelines applied
IB
4A 4B 4B1 4B5 4G 4A 4B 4B1 4B5 4G 4A 4B 4B5 4G
IIC
IC
IIB
4A 4C 4G
In the MT arm, the patients self-selected music listening during RT, and the Authors analyzed anxiety and subjective experiences. They found that anxiety decreased following RT in both arm, but MT arm were more likely to request music in future RT sessions, thus un derlying the benefits of music in terms of feeling supported and relaxed. Chen et al. [48], at the same time, evaluated the role of a simple 15-min music listening before RT, that included self-selected music tracks from different genres (pop, traditional, classical music). The Au thors analyzed the anxiety with STAI scale and physiological indicators (heart rate, respiration rate, systolic pressure) and found that MT decreased state and trait anxiety levels, as well as systolic blood pressure. Hanedan Uslu et al. [52], similarly, evaluated the effects of MT in state anxiety during RT in a prospective trial, single site, involving 72 participants. They used a music genre preference form in order to obtain tailored playlists for the patients. They investigated STAI anxiety scales, and found that after RT there was a significant decrease of STAI scores in MT arm. However, they surprisingly found a significant increase of anxiety scales in the control group after RT. Finally, Karadag et al. [49] conducted a RCT with 60 participants in Turkey. They used classical music listening interventions and monitored anxiety and depression, as well as RT comfort. MT was effective in decreasing both anxiety and depression scales in conjunction with increasing RT comfort questionnaire scores.
in oncology [14,15], its application in RT patients is still understudied. In addition it has already been demonstrated that both the treatment environment and the psychosocial climate of the RT clinic significantly impact cancer patient anxiety levels [53]. Indeed, developing a person-centered approach during RT can play a pivotal role in decreasing patient situational anxiety. In this context, MT can represent a helpful solution to adopt. For the future application of MT interventions in RT we need to know the existing research [54], so this systematic review could be useful in developing future studies in this clinical landscape. A proportion of studies reported in this review included the presence of a trained music therapist, whilst others discussed the effects of selfselected music listening. In general, all MT techniques (interactive or passive) should aim at building a relationship between the patient and the music therapist and promoting the patient’s psychophysical well-being. The role and training of the therapist plays an important role in the MT treatment as this reinforces the concept of fidelity, reproducibility and validity of the methods delivered. All these factors ensure that the procedures are administered consistently and accurately amongst the study participants, providing adherence to treatment protocols, con trolling interventional differences, reducing differences within treat ment, with minimal contamination between the study conditions [39].
3.5. Discussion and future directions
Articles may have been missed due to the search approach or because they were published after, the search was conducted. The studies were heterogeneous for interventions and outcome measures, and were small single-centre studies. The quality rating scale, at the same time, was decided by the Authors and may result in a researcher bias.
3.6. Limitations
All the findings of the selected studies should be interpreted with great caution, due to the overall low quality ratings. Specifically, all the studies were single site, the outcome measures were inconsistent and the randomization procedures were often unclear. At the same time, MT seems to be safe and effective in reducing anxiety in RT patients, although these data need to be confirmed. It is important to underline that, despite MT having a recognized role 5
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4. Conclusions
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In light of these premises, MT appears to be a promising nonpharmacological approach to cope with pain perception and mood dis orders in RT patients, supporting the traditional medicine. Nevertheless, our future research will be focused on better confirming the scientific quality of each MT intervention. This would be useful for the interpre tation and above all reliability of methods applied in each clinical setting. Further studies will be extended to a larger sample size, stratified and tailored to the needs of the patients. We need to describe more accu rately each music intervention content, delivery and approach used (from listening live or recorded music to instrumental improvisation, rhythmic auditory stimulation, songwriting, dancing or singing). The aim of these methods is not to acquire musical skills but to promote the psycho-physical well-being and positive effects on anxiety, fatigue, pain, mood and quality of life. Finally, our research will be devoted to further describe the role, qualification and credentials of the music therapist and define the standardized protocols and multicenter strategies in different clinical settings. CRediT authorship contribution statement Valerio Nardone: Conceptualization, Methodology, Writing - re view & editing. Claudia Vinciguerra: Data curation, Writing - original draft. Cesare Guida: Visualization, Investigation, Writing - original draft. Paolo Tini: Conceptualization, Methodology, Writing - original draft. Alfonso Reginelli: Writing - original draft, Supervision, Valida tion. Salvatore Cappabianca: Writing - review & editing. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi. org/10.1016/j.ctcp.2020.101124. References [1] B. Senf, J. Fettel, C. Demmerle, P. Maiwurm, Physicians’ attitudes towards psychooncology, perceived barriers, and psychosocial competencies: indicators of successful implementation of adjunctive psycho-oncological care? Psycho Oncol. 28 (2) (2019) 415–422. [2] V. Zimmermann-Schlegel, M. Hartmann, H. Sklenarova, W. Herzog, M.W. Haun, Accessibility, availability, and potential benefits of psycho-oncology services: the perspective of community-based physicians providing cancer survivorship care, Oncol. 22 (6) (2017) 719–727. [3] S.M. Lim, H.C. Kim, S. Lee, Psychosocial impact of cancer patients on their family members, Canc. Res. Treat. 45 (3) (2013) 226–233. [4] B. Schouten, B. Avau, G.T.E. Bekkering, P. Vankrunkelsven, J. Mebis, J. Hellings, et al., Systematic screening and assessment of psychosocial well-being and care needs of people with cancer, Cochrane Database Syst. Rev. 3 (2019) Cd012387. [5] J. Zabora, K. BrintzenhofeSzoc, B. Curbow, C. Hooker, S. Piantadosi, The prevalence of psychological distress by cancer site, Psycho Oncol. 10 (1) (2001) 19–28. [6] C. Zaza, S.M. Sellick, L.M. Hillier, Coping with cancer: what do patients do, J. Psychosoc. Oncol. 23 (1) (2005) 55–73. [7] L. Tang, K. Fritzsche, R. Leonhart, Y. Pang, J. Li, L. Song, et al., Emotional distress and dysfunctional illness perception are associated with low mental and physical quality of life in Chinese breast cancer patients, Health Qual. Life Outcome 15 (1) (2017) 231. [8] J. Bradt, C. Dileo, Music therapy for end-of-life care, Cochrane Database Syst. Rev. (1) (2010), Cd007169. [9] B.L. Andersen, J.A. Karlsson, B. Anderson, H.H. Tewfik, Anxiety and cancer treatment: response to stressful radiotherapy, Health Psychol. 3 (6) (1984) 535–551. [10] B.L. Andersen, H.H. Tewfik, Psychological reactions to radiation therapy: reconsideration of the adaptive aspects of anxiety, J. Pers. Soc. Psychol. 48 (4) (1985) 1024–1032. [11] H.E. Stiegelis, A.V. Ranchor, R. Sanderman, Psychological functioning in cancer patients treated with radiotherapy, Patient Educ. Counsel. 52 (2) (2004) 131–141. [12] J.D. Harrison, J.M. Young, M.A. Price, P.N. Butow, M.J. Solomon, What are the unmet supportive care needs of people with cancer? A systematic review, Support. Care Canc. 17 (8) (2009) 1117–1128.
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Complementary Therapies in Clinical Practice 39 (2020) 101124 [48] L.C. Chen, T.F. Wang, Y.N. Shih, L.J. Wu, Fifteen-minute music intervention reduces pre-radiotherapy anxiety in oncology patients, Eur. J. Oncol. Nurs. 17 (4) (2013) 436–441. € U� [49] E. Karadag, O. gur, O. Çetinayak, The effect of music listening intervention applied during radiation therapy on the anxiety and comfort level in women with early-stage breast cancer: a randomized controlled trial, Euro. J. Integr. Med. 27 (2019) 39–44. [50] C. O’Callaghan, M. Sproston, K. Wilkinson, D. Willis, A. Milner, D. Grocke, et al., Effect of self-selected music on adults’ anxiety and subjective experiences during initial radiotherapy treatment: a randomised controlled trial and qualitative research, J. Med. Imag. Radiat. Oncol. 56 (4) (2012) 473–477. [51] M. Smith, L. Casey, D. Johnson, C. Gwede, O.Z. Riggin, Music as a therapeutic intervention for anxiety in patients receiving radiation therapy, Oncol. Nurs. Forum 28 (5) (2001) 855–862. [52] G. Uslu, Influence of music therapy on the state of anxiety during radiotherapy, Turkish J. Orthod. 32 (2017). [53] T. Mullaney, K. Olausson, L. Sharp, B. Zackrisson, D. Edvardsson, T. Nyholm, The influence of a department’s psychosocial climate and treatment environment on cancer patients’ anxiety during radiotherapy, Eur. J. Oncol. Nurs. 20 (2016) 113–118. [54] A. Liberati, D.G. Altman, J. Tetzlaff, C. Mulrow, P.C. Gotzsche, J.P. Ioannidis, et al., The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration, BMJ 339 (2009) b2700.
[41] P. Barry, C. O’Callaghan, G. Wheeler, D. Grocke, Music therapy CD creation for initial pediatric radiation therapy: a mixed methods analysis, J. Music Ther. 47 (3) (2010) 233–263. [42] T.R. Alcantara-Silva, R. de Freitas-Junior, N.M.A. Freitas, W. de Paula Junior, D. J. da Silva, G.D.P. Machado, et al., Music therapy reduces radiotherapy-induced fatigue in patients with breast or gynecological cancer: a randomized trial, Integr. Canc. Ther. 17 (3) (2018) 628–635. [43] A. Rossetti, M. Chadha, B.N. Torres, J.K. Lee, D. Hylton, J.V. Loewy, et al., The impact of music therapy on anxiety in cancer patients undergoing simulation for radiation therapy, Int. J. Radiat. Oncol. Biol. Phys. 99 (1) (2017) 103–110. [44] P. Zhao, J. Liang, Q. Shao, F. Liang, H. Yuan, F. You, Interventional effects of musical therapy to physiological and psychological conditions in process of radiotherapy for patients with cancer, Chin. J. Cancer Prev. Treat. 15 (2008) 1097–1099. [45] M. Clark, G. Isaacks-Downton, N. Wells, S. Redlin-Frazier, C. Eck, J.T. Hepworth, et al., Use of preferred music to reduce emotional distress and symptom activity during radiation therapy, J. Music Ther. 43 (3) (2006) 247–265. [46] C. Elith, P. Ba, J. Ls, S. Mh, S. Dempsey, Can relaxation interventions reduce anxiety in patients receiving radiotherapy? Outcomes and study validity, Radiographer 48 (2001) 27–31. [47] J.L. Nixon, B. Brown, A.E. Pigott, J. Turner, E. Brown, A. Bernard, et al., A prospective examination of mask anxiety during radiotherapy for head and neck cancer and patient perceptions of management strategies 66 (3) (2019) 184–190.
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Contents lists available at ScienceDirect
Complementary Therapies in Clinical Practice journal homepage: http://www.elsevier.com/locate/ctcp
Music therapy and radiation oncology: State of art and future directions Valerio Nardone a, *, Claudia Vinciguerra b, Pierpaolo Correale c, Cesare Guida a, Paolo Tini d, e, Alfonso Reginelli f, Salvatore Cappabianca f a
Unit of Radiation Oncology, Ospedale Del Mare, Naples, Italy Department of Neurology, A.O.U. San Giovanni di Dio e Ruggi d’Aragona, Salerno, Italy c Unit of Medical Oncology, Grand Metropolitan Hospital “Bianchi Melacrino Morelli” Reggio Calabria, Italy d Unit of Radiation Oncology, University Hospital of Siena, Italy e Sbarro Health Research Organization, Temple University, Philadelphia, PA, USA f Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy b
A B S T R A C T
Background: Effectiveness of music-based interventions (Music therapy, MT) on cancer patients’ is a current research theme. Oncology patients may respond to radiation treatment (RT) with anxiety expressed as stress, fear, depression, and frustration. Objectives: The aim of this review is to discuss the effectiveness of MT in patients undergoing RT. Data sources: All English medical papers registered in the Web of Knowledge, PubMed, Google Scholar and ScienceDirect from March 1999 to March 2019. Inclusion and exclusion criteria: We selected all the articles concerning the use of MT in pre-RT anxiety and distress during RT treatment. Results: Out of 1184 articles selected, 132 abstracts were analyzed and 13 papers were finally evaluated for the current analysis, for a total of 946 participants. Discussion: We investigated the role and the efficacy of MT for patients receiving RT and the future challenges in the clinical management of oncology patients before and during radiotherapy.
1. Introduction Cancer diagnosis often implies extensive emotional, physical and social suffering, therefore current cancer management incorporates different psychosocial interventions in order to improve patients’ qual ity of life [1,2]. The psychological distress related to the diagnosis can be devastating for the patients and their friends and family [3]. With responses that include denial of the diagnosis, fear of death fear of recurrence of the cancer concerns about body image, the impact on sexuality, the impact on relationships, and lifestyle [4,5]. Conversely, the illness itself or the cancer treatments may lead to a radical modification of patients’ activities of daily living, especially in cases of advanced illness [6]. These conditions can have a relevant impact on patients’ quality of life [7], and eventually induce elevated levels of psychological distress, anxiety and depression [8–11]. Appropriate Psychosocial interventions are needed ranging from educational interventions to intensive counselling and integrative can cer therapies. Previous studies on advanced cancer patients treated with palliative care proved that psychosocial care (e.g. psychological, social, informational, communication, and spiritual support) constitutes a large
proportion of patients’ needs [12,13]. Amongst these interventions, music therapy (MT) is recognized as an effective treatment in cancer patients leading to a general improvement of patients’ quality of life, as it has been shown to be directly correlated with beneficial effects on anxiety, pain, fatigue, heart rate, respiratory rate and blood pressure in this population [8,14–18]. Music therapy and music medicine are now widely used as nonpharmacological interventions in different clinical and therapeutic set tings [19–22]. In the last ten years, a large number of studies conducted in people undergoing different cancer therapies for different oncological diseases, have evaluated the potential effects of music therapy (MT) employed to alleviate symptoms and treatment side effects [23–31]. Radiation therapy (RT) is one of the treatments used in cancer, and may induce important stress and anxiety in cancer patients, mainly due to the fear of RT, lack of information about treatment and side effects [32–36]. Nevertheless the role of MT for patients receiving RT is not well described, as only five studies out of fifty-two in the last Cochrane Re view of Bradt [15] dealt with MT in RT cancer patients.
* Corresponding author. Radiation Oncology Unit, Ospedale del Mare, Viale della Metamorfosi, Naples, Italy. E-mail address: [email protected] (V. Nardone). https://doi.org/10.1016/j.ctcp.2020.101124 Received 12 December 2019; Received in revised form 11 February 2020; Accepted 22 February 2020 Available online 27 February 2020 1744-3881/© 2020 Elsevier Ltd. All rights reserved.
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2. Methods
Table 1 PICO definition of linclusion criteria.
With this review we sought to address the effectiveness of MT for cancer patients undergoing RT. Improving our knowledge regarding this approach in cancer patients may provide support for exploring these interventions in clinical practice. This systematic review complies with the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [37] (see Fig. 1). Study design and criteria for exclusion/inclusion. We adopted the PICO approach to include studies (population, intervention, comparison, outcomes, study type – see Table 1). We reviewed abstract of retrieved papers:
PICO
Inclusion criteria
Population Intervention Comparison Outcomes
Radiation therapy patients Use of Music Therapy interventions With or without control groups Symptomatology (anxiety, distress, depression, pain); Physiological indices (heart rate, blood pressure, respiratory rate); Any
Study type
2.2. Data extraction and analysis Data extraction by all the authors was divided into study, partici pants and intervention characteristics, comparators, outcomes, results and limitations. The data was discussed and any discrepancies were resolved prior to final analysis. The heterogeneity amongst the different studies in terms of outcomes and assessment tools did not enable a metaanalysis of the studies to be undertaken therefore a descriptive analysis was performed.
1) Sample including patients undergoing RT; 2) There was an intervention of MT; 3) The intervention addressed the psychosocial distress of patients un dergoing RT. A comparator was intentionally not specified to ensure a comprehensive investigation of MT without limiting its comparison to a specific alternative intervention; 4) There was an evaluation of the interventions adopted;
3. Results Each researcher individually searched the database then the initial search results were merged and duplicate results removed. After 540 duplicates were removed, 1184 titles were screened for eligibility. Each researcher independently assessed 132 eligible ab stracts. Studies were excluded following the fore-mentioned inclusion criteria and PICO strategy. Discrepancies were resolved on a case-bycase basis by discussion. Through this procedure, 13 original articles were identified for inclusion in the final review. Full text copies of the articles were obtained, and results and out comes were extracted in order to tabulate the details of the selected articles. Each relevant article was scored using the quality rating adopted by Keim-Malpass, Letzkis and Kennedy [38] (see Table 2) and the Robb’s music-based reporting guidelines [39] (see Table 3). Fig. 1 represents the process of screening and selection of the articles, in order to obtain the final 13 articles for review, which consist of 13 studies for a total of 946 participants.
If these criteria were met, papers were obtained and reviewed in full. Exclusion criteria were: intervention addressed patients undergoing chemotherapy, surgery or other form of radiation (i.e.: diagnostic im aging). Grey literature, including conference lectures, case reports, commentary papers. Reviews and systematic reviews were at the same time excluded. 2.1. Search strategy The systematic review was conducted by searching all English medical papers registered in the web of Knowledge, PubMed, Google Scholar, Science Direct, Embase and Cochrane Library from 1991 to 2019. The search strategy was “music therapy and radiotherapy” or “radiation and music”. We also took into account the references of other reviews, as well as those of the selected articles, to include other papers. Two reviewers (VN and CV) independently appraised the eligible studies with any disputes resolved collaboratively after discussion.
3.1. Participants’ characteristics and interventions used The sample population ranged from 11 to 200 participants and all the selected studies were single-site studies. The interventions used were Table 2 Summary of quality scoring criteria. Rating number (design)
Details
LEVEL I LEVEL II LEVEL III LEVEL IV Rating rank (quality) A-HIGH
Randomized control trial (RCT) Quasi-experimental trial Non experimental trial Qualitative Details
B-GOOD
Fig. 1. Workflow of the systematic review process, according to the guidelines for Preferred Reporting Items for Systematic Reviews and MetaAnalyses (PRISMA).
C-LOW
2
Consistent, generalizable results, sufficient sample size, adequate control, definitive conclusions, consistent recommendations based on comprehensive literature review that includes thorough reference to scientific evidence Reasonably consistent results, sufficient sample size for the study design, some control, fairly definitive conclusions, reasonably consistent recommendations based on fairly comprehensive literature review that includes some reference to scientific evidence Little evidence with inconsistent results, insufficient sample size for the study design, conclusions cannot be drawn
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Rossetti A et al. [43] also evaluated the impact of MT on anxiety and distress in patients with newly diagnosed head and neck or breast can cer. The intervention was a music listening session with a trained music therapist before simulation CT, and the measure of outcomes included pre-State-Trait Anxiety Inventory (STAI-S Anxiety) questionnaire and Symptom Distress Thermometer (SDT). The results showed that the MT significantly lowered patient anxiety and distress during the clinical procedure. ^ntara-Silva et al. [42] in their randomized controlled trial Alca investigated the influence of MT on the reduction of fatigue in women with breast or gynecological malignancies under radiotherapy. 30–40 min individual sessions of music therapy with a trained music therapist were offered to participants of the experimental arm, and the Authors analyzed fatigue and depression. On the basis of the reduction of both outcomes in the experimental arm, the Authors concluded that indi vidual MT sessions are effective to reduce fatigue related to cancer and symptoms of depression as well as to improve quality of life for the specific population.
Table 3 Music-Based Intervention Guidelines reporting by Robb’s et al. Music based interventions components reccomended
Details
4 A Intervention Theory
To Provide a rationale for the music selected, specifying how qualities and delivery of the music are expected to impact targeted outcomes. To Provide precise details of the music intervention and, when applicable, descriptions of procedures for tailoring interventions to individual participants To specify who preselect the music (investigator, participant selected from limited set, participant selected from own collection, or tailored based on patient assessment). To provide reference for sheet music or sound recording (when using published music) To specify who delivered the live music and the size of the performance group (e.g., interventionist only, interventionist and participant). Specify music and/or non-music materials. Describe music-based intervention strategies under investigation (examples: music listening, songwriting, improvisation, lyric analysis, rhythmic auditory stimulation, etc) To report number of sessions, session duration, and session frequency including practice sessions Specify interventionist qualifications and credentials. Specify how many interventionists delivered study conditions. Describe strategies used to ensure that treatment and/or control conditions were delivered as intended (e.g., interventionist training, manualized protocols, and intervention monitoring) Describe where the intervention was delivered; include location, privacy level, and ambient sound. Specify whether interventions were delivered to individuals or groups of individuals, including the size of the group
4 B Intervention Content
4 B1 Music selection.
4 B2 Music sources details 4 B3 Music Delivery Method (Live or Recorded). 4 B4 Intervention Materials 4 B5 Intervention Strategies.
4C Intervention Delivery Schedule 4D Interventionist. 4E Fidelity Strategies for Treatment Delivery
4F Setting. 4G Unit of Delivery.
3.3. Relaxation techniques including music In 2001 (CIT). Elith et al. [46] produced one of the first reports of MT applied to RT patients. They applied different relaxation techniques (MT, aromatherapy and guided imagery) in a small prospective study that included 14 participants. They analyzed anxiety with STAI scale and concluded that each of the adopted techniques could provide clin ical reduction of anxiety. Clark et al. [45] adopted in a RCT self-initiated strategies used to relax, including deep breathing, visual imagery, muscle relaxation. In addition to these strategies, experimental group patients performed two additional activities: music listening and music used to create a visual image, with the guide of a trained music therapist. The Authors analyzed fatigue, pain, anxiety and depression and found that anxiety and distress were significantly lower in the experimental arm and that there was a consistent correlation between number of times music was used and the change in treatment-related distress. Nixon et al. [47] analyzed different strategies to reduce anxiety in patients requiring thermoplastic mask during RT (defined as “mask anxiety”). Such strategies consist into discussions with health pro fessionals, self-taught strategies and music listening. The outcomes included distress thermometer for mask anxiety, and it was found that music listening was helpful in reducing the distress in the case of 72% of participants.
placed into two categories: interventions used before RT and in terventions used during the RT procedure. In adult patients, the outcome measures in the studies differed and included fatigue assessment, anxi ety evaluation, depression evaluation and clinical assessments. The studies involving pediatric patients, used clinical evaluation [40] or specific outcome questionnaires [41]. The interventions were diverse amongst the studies, including ses sions with a trained music therapist [40,42–44], relaxation techniques combined with music [45–47], music listening before or during RT [41, 48–52]. We will briefly describe the different strategies of MT according to the previous classification (see Table 4 for details of the studies included).
3.4. Music listening before and during RT Music listening before and during RT was the most commonly used technique of MT in RT, as this strategy is both simple and efficacious. The first example of music listening during RT was reported in the work of Maureen Smith et al., in 2001 [51], a RCT involving 42 par ticipants. The experimental arm used self-selected music listening dur ing RT and the Authors analyzed anxiety with STAI scale. The results showed that there were no significant differences among the groups, albeit in post-hoc analysis there was a trend suggesting some benefits in MT arm. On the other hand Barry et al. [41] conducted a very small single site RCT involving 11 pediatric patients undergoing RT. They investigated the potential use of a MT compact disc created by the involved children using interactive computer-based music software in turn remixed by the music therapist-researcher. The Authors investigated the patients, par ents and RT professional’s perceptions of distress and efficacy together with the Kidscope questionnaire. Unfortunately, they found no differ ences in outcomes as well as lack of congruence among groups. At the same time, MT was considered enjoyable, supportive and helpful for both patients and families. O’ Callaghan et al. [50] also conducted a RCT with 100 participants.
3.2. MT with trained music therapist O’Callaghan et al. [40] was the first report of MT performed with a music therapist, in a pediatric setting. They placed musical instrument in a dedicated space, and encouraged both patients and families to “play” with a music therapist, thus increasing the means of communication, self-expression and creativity. The outcome measure was the clinical evaluation, and a range of benefits were perceived, such as stress relief, physical and psychosocial improvements, facilitation of the clinical communication. Zhao et al. [44] performed a 30 min specific music intervention before RT in a cohort of 95 patients. The Authors measured anxiety and physiological indices and found that with MT both the outcomes were substantially lower in the experimental arm. 3
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Table 4 Study details. Author, Year, Place
Type
Number of patients
Interventions
Measure of outcomes
Results
Rating Number (design) and Rank (quality)
Robb’s music-based reporting guidelines applied
AlcantaraSilva et al., 2018, Brazil
RCT, single site;
116 patients (63 control arm, 53 sperimental arm);
30–40 min of a music therapy session with a trained music therapist
� FACT-F results were significant regarding Trial Outcome Index (P ¼ .011), FACT-G (P ¼ .005), and FACT-F (P ¼ .001) for the sperimental arm compared with the control arm;
IB
4A 4B1 4C 4D 4F 4G
Barry et al., 2010, Australia
Small RCT, single site
11 participants (5 sperimental arm, 6 control arm);
Music Therapy Compact Disc (CD);
✓ Functional Assessment of Cancer Therapy: Fatigue (FACT-F) version 4; ✓ Functional Assessment of Cancer Therapy–General (FACT-G) version 4; ✓ Beck Depression Inventory; ✓ 3 separate times; ✓ Kidscope questionnaire; ✓ Parental perceptions of the efficacy; ✓ Patient, parents and RT perceptions of distress;
IIC
4A 4B 4B1 4B3 4B5 4D 4G
Chen et al., 2013, Taiwan
RCT study, single site;
200 participants (100 sperimental arm, 100 control arm);
Fifteen-minute music intervention before RT;
✓ State-Trait Anxiety Inventory; ✓ Physiological indicators of anxiety;
IB
4A 4B 4B1 4B3 4B5 4C 4G
Clark et al., 2006, US;
RCT, single site;
63 participants (35 experimental arm, 28 control arm);
✓ Single item distress numeric rating scale or fatigue and pain (NRS); ✓ Hospital Anxiety and Depression Scale (HAD); ✓ Profile of Mood States (POMS) Fatigue;
IIC
4A 4B 4B1 4B3 4B4 4B5 4G
Elith et al., 2001, Australia;
Small prospective study, single site;
14 participants (7 experimental arm, 7 control arm);
✓ State-Trait Anxiety Inventory;
� Clinical reduction in anxiety levels in each of the three relaxation interventions compared to control arm;
IIC
4A 4B 4B4
Karadag et al., 2019, Turkey;
RCT, single site;
60 participants (30 eperimental arm, 30 control arm);
Self-initiated strategies used to relax for all the patients (deep breathing, visual imagery, muscle relaxation and other; experimental group completed two additional items: listened to the mood and flow of the music, and used music to create a visual image, guided by a trained music therapist; Three relaxation intervention techniques (music therapy, aromatherapy, guided imagery); Music listening intervention (classical music);
� No differences in time in treatment room, distress; � Lack of congruence in ratings among groups; � Music therapy was considered fun, supportive and helpful for children and families; � Baseline State/Trait scores and vital signis comparable between groups; � After intervention, statistically significant decrease in State-Trait anxi ety scores and systolic pres sure in experimental arm; � Anxiety and distress were significantly lower for experimental arm than control arm; � Within the experimental arm, there was a significant correlation between number of times music was used and the change in treatmentrelated distress;
� Significant difference in HAD-A (p < 0,001), HAD-D (p < 0,001) and RTCQ scores (p < 0,001);
IIB
4A 4B 4B3 4G
Nixon et al., 2019, Australia;
Prospective study, single site;
35 participants (cohort study);
✓ Hospital Anxiety and Depression Scale (HAD); ✓ Radiation Therapy Comfort Questionnaire (RTCQ); ✓ Distress Thermometer (DT) for mask anxiety;
� Music listening was reported helpful in reducing DT for 72% of the participants;
IIIC
4A 4B 4B5 4G
O0
Descriptive study, single site;
60 participants (cohort study);
✓ Clinical evaluation;
IIIC
RCT, single site;
100 participants (50 experimental arm, 50 control arm);
� A range of benefits were perceived, from temporary respite from stress, to physical and psychosocial improvements; � Clinical communication facilitated; � Anxiety decreased following RT in both arms; � Music group patients were significantly more likely to
4A 4B 4B1 4B3 4D 4F 4G 4A 4B1 4B3 4B5 4G
O0
Callaghan et al., 2007, Australia;
Callaghan et al., 2012, Australia;
Different strategies to reduce anxiety in patients requiring thermoplastic mask during RT (discussions with health professionals, self-taught strategies, music listening); Music therapy (passive and active) in sessions with a trained music therapist;
Self selected music listening during RT;
✓ State-Trait Anxiety Inventory; ✓ Subjective experience;
IC
(continued on next page)
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Complementary Therapies in Clinical Practice 39 (2020) 101124
Table 4 (continued ) Author, Year, Place
Type
Number of patients
Interventions
Measure of outcomes
Rossetti et al., 2017, US;
RCT, single site;
78 participants (39 experimental arm, 39 control arm);
Music session listening with a trained music therapist before simulation CT;
✓ State-Trait Anxiety Inventory; ✓ Symptom Distress Thermometer (SDT);
Smith et al., 2001, US;
RCT, single site;
42 participants (19 experimental arm, 23 control arm);
Self selected music listening during simulation and RT;
✓ State-Trait Anxiety Inventory;
Hanedan Uslu, 2017, Turkey;
Prospective Trial, single site;
72 participants (36 experimental arm, 36 control arm);
Patient tailored music listening during RT;
✓ State-Trait Anxiety Inventory;
Zhao et al., 2008, China;
RCT, single site;
95 participants
30 min of music intervention;
✓ Zung Anxiety scale (SAS); ✓ Hama Anxiety scale (HAMA); ✓ Physiological indices;
Results
want music in future RT sessions (p:0,007); � Benefit of music in terms of feeling supported, distracted; � Music Intervention significantly lowered STAI and SDT scores; � No significant differences between the two groups; � In post-hoc analysis changes and trends suggesting benefit of music therapy; � After RT, significant decrease (p:0,001) of STAI scores in experimental group, and significant increase (p:0,003) in control group; � Physiological indices, SAS and HAMA scores were significantly lower in experimental arm than control group (p < 0,05), as well as before RT and after RT in the experimental arm (p < 0,05);
Rating Number (design) and Rank (quality)
Robb’s music-based reporting guidelines applied
IB
4A 4B 4B1 4B5 4G 4A 4B 4B1 4B5 4G 4A 4B 4B5 4G
IIC
IC
IIB
4A 4C 4G
In the MT arm, the patients self-selected music listening during RT, and the Authors analyzed anxiety and subjective experiences. They found that anxiety decreased following RT in both arm, but MT arm were more likely to request music in future RT sessions, thus un derlying the benefits of music in terms of feeling supported and relaxed. Chen et al. [48], at the same time, evaluated the role of a simple 15-min music listening before RT, that included self-selected music tracks from different genres (pop, traditional, classical music). The Au thors analyzed the anxiety with STAI scale and physiological indicators (heart rate, respiration rate, systolic pressure) and found that MT decreased state and trait anxiety levels, as well as systolic blood pressure. Hanedan Uslu et al. [52], similarly, evaluated the effects of MT in state anxiety during RT in a prospective trial, single site, involving 72 participants. They used a music genre preference form in order to obtain tailored playlists for the patients. They investigated STAI anxiety scales, and found that after RT there was a significant decrease of STAI scores in MT arm. However, they surprisingly found a significant increase of anxiety scales in the control group after RT. Finally, Karadag et al. [49] conducted a RCT with 60 participants in Turkey. They used classical music listening interventions and monitored anxiety and depression, as well as RT comfort. MT was effective in decreasing both anxiety and depression scales in conjunction with increasing RT comfort questionnaire scores.
in oncology [14,15], its application in RT patients is still understudied. In addition it has already been demonstrated that both the treatment environment and the psychosocial climate of the RT clinic significantly impact cancer patient anxiety levels [53]. Indeed, developing a person-centered approach during RT can play a pivotal role in decreasing patient situational anxiety. In this context, MT can represent a helpful solution to adopt. For the future application of MT interventions in RT we need to know the existing research [54], so this systematic review could be useful in developing future studies in this clinical landscape. A proportion of studies reported in this review included the presence of a trained music therapist, whilst others discussed the effects of selfselected music listening. In general, all MT techniques (interactive or passive) should aim at building a relationship between the patient and the music therapist and promoting the patient’s psychophysical well-being. The role and training of the therapist plays an important role in the MT treatment as this reinforces the concept of fidelity, reproducibility and validity of the methods delivered. All these factors ensure that the procedures are administered consistently and accurately amongst the study participants, providing adherence to treatment protocols, con trolling interventional differences, reducing differences within treat ment, with minimal contamination between the study conditions [39].
3.5. Discussion and future directions
Articles may have been missed due to the search approach or because they were published after, the search was conducted. The studies were heterogeneous for interventions and outcome measures, and were small single-centre studies. The quality rating scale, at the same time, was decided by the Authors and may result in a researcher bias.
3.6. Limitations
All the findings of the selected studies should be interpreted with great caution, due to the overall low quality ratings. Specifically, all the studies were single site, the outcome measures were inconsistent and the randomization procedures were often unclear. At the same time, MT seems to be safe and effective in reducing anxiety in RT patients, although these data need to be confirmed. It is important to underline that, despite MT having a recognized role 5
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4. Conclusions
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In light of these premises, MT appears to be a promising nonpharmacological approach to cope with pain perception and mood dis orders in RT patients, supporting the traditional medicine. Nevertheless, our future research will be focused on better confirming the scientific quality of each MT intervention. This would be useful for the interpre tation and above all reliability of methods applied in each clinical setting. Further studies will be extended to a larger sample size, stratified and tailored to the needs of the patients. We need to describe more accu rately each music intervention content, delivery and approach used (from listening live or recorded music to instrumental improvisation, rhythmic auditory stimulation, songwriting, dancing or singing). The aim of these methods is not to acquire musical skills but to promote the psycho-physical well-being and positive effects on anxiety, fatigue, pain, mood and quality of life. Finally, our research will be devoted to further describe the role, qualification and credentials of the music therapist and define the standardized protocols and multicenter strategies in different clinical settings. CRediT authorship contribution statement Valerio Nardone: Conceptualization, Methodology, Writing - re view & editing. Claudia Vinciguerra: Data curation, Writing - original draft. Cesare Guida: Visualization, Investigation, Writing - original draft. Paolo Tini: Conceptualization, Methodology, Writing - original draft. Alfonso Reginelli: Writing - original draft, Supervision, Valida tion. Salvatore Cappabianca: Writing - review & editing. Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi. org/10.1016/j.ctcp.2020.101124. References [1] B. Senf, J. Fettel, C. Demmerle, P. Maiwurm, Physicians’ attitudes towards psychooncology, perceived barriers, and psychosocial competencies: indicators of successful implementation of adjunctive psycho-oncological care? Psycho Oncol. 28 (2) (2019) 415–422. [2] V. Zimmermann-Schlegel, M. Hartmann, H. Sklenarova, W. Herzog, M.W. Haun, Accessibility, availability, and potential benefits of psycho-oncology services: the perspective of community-based physicians providing cancer survivorship care, Oncol. 22 (6) (2017) 719–727. [3] S.M. Lim, H.C. Kim, S. Lee, Psychosocial impact of cancer patients on their family members, Canc. Res. Treat. 45 (3) (2013) 226–233. [4] B. Schouten, B. Avau, G.T.E. Bekkering, P. Vankrunkelsven, J. Mebis, J. Hellings, et al., Systematic screening and assessment of psychosocial well-being and care needs of people with cancer, Cochrane Database Syst. Rev. 3 (2019) Cd012387. [5] J. Zabora, K. BrintzenhofeSzoc, B. Curbow, C. Hooker, S. Piantadosi, The prevalence of psychological distress by cancer site, Psycho Oncol. 10 (1) (2001) 19–28. [6] C. Zaza, S.M. Sellick, L.M. Hillier, Coping with cancer: what do patients do, J. Psychosoc. Oncol. 23 (1) (2005) 55–73. [7] L. Tang, K. Fritzsche, R. Leonhart, Y. Pang, J. Li, L. Song, et al., Emotional distress and dysfunctional illness perception are associated with low mental and physical quality of life in Chinese breast cancer patients, Health Qual. Life Outcome 15 (1) (2017) 231. [8] J. Bradt, C. Dileo, Music therapy for end-of-life care, Cochrane Database Syst. Rev. (1) (2010), Cd007169. [9] B.L. Andersen, J.A. Karlsson, B. Anderson, H.H. Tewfik, Anxiety and cancer treatment: response to stressful radiotherapy, Health Psychol. 3 (6) (1984) 535–551. [10] B.L. Andersen, H.H. Tewfik, Psychological reactions to radiation therapy: reconsideration of the adaptive aspects of anxiety, J. Pers. Soc. Psychol. 48 (4) (1985) 1024–1032. [11] H.E. Stiegelis, A.V. Ranchor, R. Sanderman, Psychological functioning in cancer patients treated with radiotherapy, Patient Educ. Counsel. 52 (2) (2004) 131–141. [12] J.D. Harrison, J.M. Young, M.A. Price, P.N. Butow, M.J. Solomon, What are the unmet supportive care needs of people with cancer? A systematic review, Support. Care Canc. 17 (8) (2009) 1117–1128.
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