Music interventions for improving psychological and physical outcomes in people with cancer
This is an update of the review published on the Cochrane Library in 2016, Issue 8. Having cancer may result in extensive emotional, physical and social suffering. Music interventions have been used to alleviate symptoms and treatment side effects in people with cancer. This review includes music interventions defined as music therapy offered by trained music therapists, as well as music medicine, which was defined as listening to pre‐recorded music offered by medical staff.
To assess and compare the effects of music therapy and music medicine interventions for psychological and physical outcomes in people with cancer.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 3) in the Cochrane Library, MEDLINE via Ovid, Embase via Ovid, CINAHL, PsycINFO, LILACS, Science Citation Index, CancerLit, CAIRSS, Proquest Digital Dissertations, ClinicalTrials.gov, Current Controlled Trials, the RILM Abstracts of Music Literature, http://www.wfmt.info/Musictherapyworld/ and the National Research Register. We searched all databases, except for the last two, from their inception to April 2020; the other two are no longer functional, so we searched them until their termination date. We handsearched music therapy journals, reviewed reference lists and contacted experts. There was no language restriction.
We included all randomized and quasi‐randomized controlled trials of music interventions for improving psychological and physical outcomes in adults and pediatric patients with cancer. We excluded patients undergoing biopsy and aspiration for diagnostic purposes.
Data collection and analysis
Two review authors independently extracted the data and assessed the risk of bias. Where possible, we presented results in meta‐analyses using mean differences and standardized mean differences. We used post‐test scores. In cases of significant baseline difference, we used change scores. We conducted separate meta‐analyses for studies with adult participants and those with pediatric participants. Primary outcomes of interest included psychological outcomes and physical symptoms and secondary outcomes included physiological responses, physical functioning, anesthetic and analgesic intake, length of hospitalization, social and spiritual support, communication, and quality of life (QoL) . We used GRADE to assess the certainty of the evidence.
We identified 29 new trials for inclusion in this update. In total, the evidence of this review rests on 81 trials with a total of 5576 participants. Of the 81 trials, 74 trials included adult (N = 5306) and seven trials included pediatric (N = 270) oncology patients. We categorized 38 trials as music therapy trials and 43 as music medicine trials. The interventions were compared to standard care.
The results suggest that music interventions may have a large anxiety‐reducing effect in adults with cancer, with a reported average anxiety reduction of 7.73 units (17 studies, 1381 participants; 95% confidence interval (CI) ‐10.02 to ‐5.44; very low‐certainty evidence) on the Spielberger State Anxiety Inventory scale (range 20 to 80; lower values reflect lower anxiety). Results also suggested a moderately strong, positive impact of music interventions on depression in adults (12 studies, 1021 participants; standardized mean difference (SMD): −0.41, 95% CI −0.67 to −0.15; very low‐certainty evidence). We found no support for an effect of music interventions on mood (SMD 0.47, 95% CI −0.02 to 0.97; 5 studies, 236 participants; very low‐certainty evidence). Music interventions may increase hope in adults with cancer, with a reported average increase of 3.19 units (95% CI 0.12 to 6.25) on the Herth Hope Index (range 12 to 48; higher scores reflect greater hope), but this finding was based on only two studies (N = 53 participants; very low‐certainty evidence).
We found a moderate pain‐reducing effect of music interventions (SMD −0.67, 95% CI −1.07 to −0.26; 12 studies, 632 adult participants; very low‐certainty evidence). In addition, music interventions had a small treatment effect on fatigue (SMD −0.28, 95% CI −0.46 to −0.10; 10 studies, 498 adult participants; low‐certainty evidence).
The results suggest a large effect of music interventions on adult participants' QoL, but the results were highly inconsistent across studies, and the pooled effect size was accompanied by a large confidence interval (SMD 0.88, 95% CI −0.31 to 2.08; 7 studies, 573 participants; evidence is very uncertain). Removal of studies that used improper randomization methods resulted in a moderate effect size that was less heterogeneous (SMD 0.47, 95% CI 0.06 to 0.88, P = 0.02, I2 = 56%).
A small number of trials included pediatric oncology participants. The findings suggest that music interventions may reduce anxiety but this finding was based on only two studies (SMD −0.94, 95% CI −1.9 to 0.03; very low‐certainty evidence). Due to the small number of studies, we could not draw conclusions regarding the effects of music interventions on mood, depression, QoL, fatigue or pain in pediatric participants with cancer.
The majority of studies included in this review update presented a high risk of bias, and therefore the overall certainty of the evidence is low. For several outcomes (i.e. anxiety, depression, pain, fatigue, and QoL) the beneficial treatment effects were consistent across studies for music therapy interventions delivered by music therapists. In contrast, music medicine interventions resulted in inconsistent treatment effects across studies for these outcomes.
This systematic review indicates that music interventions compared to standard care may have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. The results of two trials suggest that music interventions may have a beneficial effect on anxiety in children with cancer. Too few trials with pediatric participants were included to draw conclusions about the treatment benefits of music for other outcomes. For several outcomes, music therapy interventions delivered by a trained music therapist led to consistent results across studies and this was not the case for music medicine interventions. Moreover, evidence of effect was found for music therapy interventions for QoL and fatigue but not for music medicine interventions. Most trials were at high risk of bias and low or very low certainty of evidence; therefore, these results need to be interpreted with caution.
Joke Bradt, Cheryl Dileo, Katherine Myers-Coffman, Jacelyn Biondo
Plain language summary
Can music interventions benefit people with cancer?
The issue-Cancer may result in extensive emotional, physical and social suffering. Music therapy and music medicine interventions have been used to alleviate symptoms and treatment side effects and address psychosocial needs in people with cancer. In music medicine interventions, patients simply listen to pre‐recorded music that is offered by a medical professional. Music therapy requires the implementation of a music intervention by a trained music therapist, the presence of a therapeutic process and the use of personally tailored music experiences.
The aim of the review-This review is an update of a previous Cochrane review from 2016, which included 52 studies. For this review update, we searched for additional trials studying the effect of music interventions on psychological and physical outcomes in people with cancer. We searched for studies up to April 2020.
What are the main findings?-We identified 29 new studies, so the evidence in this review update now rests on 81 studies with 5576 participants. Of the 81 studies, 74 trials included adults and 7 included children.The findings suggest that music therapy and music medicine interventions may have a beneficial effect on anxiety, depression, hope, pain, fatigue, heart rate and blood pressure in adults with cancer. Music therapy but not music medicine interventions may improve adult patients' quality of life and levels of fatigue. We did not find evidence that music interventions improve mood, distress or physical functioning, but only a few trials studied these outcomes. We could not draw any conclusions about the effect of music interventions on immunologic functioning, resilience, spiritual well‐being or communication outcomes in adults because there were not enough trials looking at these aspects. Due to the small number of trials, we could not draw conclusions for children. Therefore, more research is needed.
Overall, the treatment benefits of music therapy interventions were more consistent across trials than those of music medicine interventions, leading to greater confidence in the treatment impact of music therapy interventions delivered by a trained music therapist.
No adverse effects of music interventions were reported.
Quality of the evidence-Most trials were at high risk of bias, so these results need to be interpreted with caution. We did not identify any conflicts of interests in the included studies.
What are the conclusions?-We conclude that music interventions may have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. Furthermore, music may have a small positive effect on heart rate and blood pressure. Reduction of anxiety, depression, fatigue and pain are important outcomes for people with cancer, as they have an impact on health and overall quality of life.
Joke Bradt, Cheryl Dileo, Katherine Myers-Coffman, Jacelyn Biondo
Implications for practice
This systematic review indicates that music interventions may have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. Music therapy interventions had a moderate effect on QoL in adults, whereas we found no support for an effect for music medicine studies. Furthermore, the results suggest that music may reduce heart rate and blood pressure, though this reduction is rather small and therefore may not be clinically significant. Results from single trials suggest that music listening in cancer patients undergoing surgery may reduce anesthetic and analgesic consumption and reduce the length of hospital stay, but more research is needed before drawing solid conclusions. Results from a single study furthermore suggest that post‐surgery recovery time may be shortened when a music therapist offers live, individualized music before and during surgery. Overall, evidence of the trials included in this review suggest that music interventions may be offered as a complementary treatment to adults with cancer and that music therapy interventions delivered by a trained music therapist may lead to more consistent results.
No evidence of effect was found for distress, mood, physical functioning, or oxygen saturation. However, only a small number of trials investigated the effects of music on these outcomes. More research is needed. We cannot draw any conclusions at this time regarding the effects of music interventions on resilience, spiritual well‐being, mean arterial pressure, immunologic functioning or communication behaviours in adults because the results of the studies that included these outcomes could not be pooled or because we could only identify one trial.
A small number of trials included pediatric oncology participants. Not all trials included the same outcomes, therefore, we could only compute pooled effect sizes for a small number of outcomes. Those findings suggest that music interventions may reduce anxiety, but no evidence of an effect was found for distress or spiritual well‐being. However, there were only two trials included for each of these outcomes, thus more research is needed. At this time, we cannot draw conclusions regarding the effects of music interventions on mood, resilience, coping, QoL, communication behaviors, pain, or physiological responses in pediatric patients with cancer, because the results of the studies that included these outcomes could not be pooled or because we could only identify one trial.
Because participants cannot be blinded to music interventions and subjective outcomes are measured by self‐report measures, there was a high risk of bias for most studies. Therefore, the findings of this review need to be interpreted with caution.
Implications for research
This systematic review provides evidence that music interventions may have beneficial effects on anxiety, depression, hope, pain, fatigue, heart rate and blood pressure in adults with cancer. Only a few trials with pediatric participants were included and therefore no conclusions can be drawn at this time regarding the impact of music interventions on pediatric oncology patients. Comparative analyses between music therapy and music medicine interventions indicate that music therapy is more effective in improving QoL and fatigue than music medicine interventions. Moreover, the treatment effects of music therapy interventions show greater consistency across studies than music medicine interventions for anxiety, depression, and pain. At this time, more RCTs are needed to determine the effectiveness of music medicine versus music therapy for other outcomes in this review. This can be achieved by including more music medicine as well as music therapy RCTs in future reviews, when these become available or, alternatively, future trials could directly compare the effects of these two types of interventions. It is important to note that Bradt 2015 undertook such a comparative study based on the recommendation of the original systematic review, concluding that both music therapy and music medicine interventions were similarly effective for symptom management. However, the results of their mixed methods research study clearly indicated that even listening to pre‐recorded music can evoke strong emotions and existential issues in people with cancer and that the participants in this study were grateful for the presence of a music therapist to process these emotions and fears. Participants furthermore emphasized the importance of interactive music‐making, as it allowed them to access their creativity; this is considered an important resource for the facilitation of resilience in the face of life's challenges.--Future research should explore patient characteristics as moderators of treatment benefits of music therapy interventions versus listening to pre‐recorded music. For example, Bradt 2015 suggested that listening to music may cause distress in patients who have a negative outlook on life. It is possible that these patients are at greater risk for music's powerful capacity to access sad and traumatic memories, and such patients may be better served by listening to music in the presence of a music therapist who can help them process their emotions. On the other hand, Bradt and colleagues emphasized that some patients have a great need for stability and emotional security during this challenging time in their life and may therefore prefer the familiarity of their own music. Self‐selected music presents predictable musical and emotional content and may, therefore, provide a much needed holding environment for the patient.
We recommend that future research efforts aim to enhance understanding of how music therapy and music medicine interventions can be optimized for symptom management, how music interventions can best serve patients along the cancer treatment trajectory, and what unique aspects of music therapy and music medicine interventions contribute to the care of patients (Bradt 2015).
As stated in other reviews, it is important that investigators consider qualitative and mixed methods research, as these enhance understanding of the qualitative aspects of a patient's experience and identify factors that may contribute to or limit the effectiveness of music therapy or music medicine interventions (Bradt 2010; Bradt 2013a; Bradt 2014).
Future trials that use listening to pre‐recorded music should report more details related to the music selections made available to participants and exercise greater care in selecting music that reflects the patient's true preference (rather than just giving the patient the option to select from four or five general genres). It is recommended that reporting guidelines for music‐based interventions as outlined by Robb 2010 are used in clinical trial reports. In addition, researchers need to carefully consider the potential negative impact of the use of headphones during procedures because of hampered communication between the patient and medical personnel.
More research is needed that examines the relationship between frequency and duration of music interventions and treatment effects.
Many trials used small sample sizes and did not indicate the use of power calculations. Future trials need to include power calculations in order to use adequate sample sizes.
More studies are needed on the use of music interventions in pediatric patients with cancer. Of the 81 trials in this review, only seven studies focused on outcomes in children and adolescents.
Many studies examined the effects of music interventions on anxiety. Given that the findings regarding anxiety‐reducing effects of music are quite robust, it is important that future studies focus on other outcomes included in this review.
Formal cost‐benefit evaluations of music medicine and music therapy are needed.