Introduction
Cancer is one of the most serious and common health
problems worldwide that result in death. It accounts
for 13% of the mortality rates in developed countries,
and is the second most frequent cause of death after
ischemic heart disease.[] Current treatment of cancer
involves surgery, chemotherapy, and radiotherapy. Approximately 4 of 10 patients (40%) with cancer receive
radiotherapy at some point of their treatment. Radiotherapy
is used to treat different types of cancer, and
may be administered before or after surgery as a solitary
treatment or in combination with chemotherapy.
Radiotherapy is often administered for 2?5 weeks with
doses in multiple daily fractions.
Patients experience several side effects during the treatment process. In particular, along with various
physical side effects, emotional and social problems,
such as anxiety, depression, fear, loneliness, and hopelessness,
may be experienced as a result of long-term
treatment and uncertainty.[,] Among these, anxiety
is one of the most common symptoms. The incidence
of anxiety in cancer patients is >50%, and approximately
30% of the patients suffer from chronic anxiety.[]
Studies in Canada, Australia, and the USA demonstrated
that 42%?75% of cancer outpatients with elevated
anxiety and depression levels do not have access to psychological
support.[-] Mackenzie recently reported
that 50% of radiation oncology outpatients experience
anxiety.[] The American Psychological Association
defines anxiety as an emotion characterized by feelings
of tension, worried thoughts, and physical changes,
such as increased blood pressure..[] Anxiety often
coexists with depression and affects patients" quality of
life.[,] Anxiety as one of the most common psychosocial
disorders causes further problems, including
fatigue, sleep disturbances, eating disorders, increased
heart rate, and high blood pressure.[] Furthermore,
anxiety also has an adverse effect on the continuity and
potential benefits of treatment as it results in negative
emotions.[,]
The oncology team aims to use a holistic approach
to support the patient while providing an efficient
therapy. Currently, various alternatives for supportive
care are available. Music therapy is one of the alternative
methods used to reduce anxiety.[] In 2005, the
American Music Therapy Association defined music
therapy as the clinical and evidence-based use of music
to accomplish individual goals in a therapeutic relationship
by a credential professional who has completed
an approved music therapy program.[] The
use of music therapy as a treatment option dates back
to centuries. It was first used by Paragiter in the early
18th century and Dogiel in 1830, especially in patients
with psychiatric disorders and those in the intensive
care unit and operating rooms.[,] Music therapy
was suggested to influence physiological responses by
affecting blood circulation and pressure. The first use
of music therapy in hospitals was in the fields of anesthesiology
and analgesia. In the mid-20th century,
researchers began to develop theories to explain the
neurological basis of music therapy and investigated
the effects of music therapy on physiological parameters.[]
Music therapy is an evidence-based complementary
treatment method, which is frequently used as a part
of integrative oncological treatment programs.[] It is used to improve, maintain, remediate, or prevent one
or more clinical issues in patients according to their
specific needs for habilitation and rehabilitation.[]
Although both quantitative results [,] and qualitative
outcomes [] of music therapy are promising in
terms of reducing anxiety and stress levels in patients
receiving radiotherapy, music therapy procedures described
in previous studies are diverse.[]
Despite studies in the literature regarding the use
of music therapy to reduce anxiety levels in patients
receiving radiotherapy, no such study has been conducted
in Turkey. The present study hypothesized that
patients who receive music therapy by listening to the
songs of their choice experience lower levels of anxiety
than those who do not receive music therapy.
Methods
The present study was conducted to evaluate the effects
of music therapy using songs of patients" choice
on anxiety state during radiotherapy. The research was
conducted in the department of radiation oncology
at a university hospital in the East Black Sea Region,
Turkey. Inclusion criteria included patients aged ?18
years, with a life expectancy of ?6 months, who were
receiving radiotherapy, who could speak Turkish, and
who volunteered to participate in the study. Exclusion
criteria included patients with visual and hearing
impairment who were receiving radiotherapy to the
brain region due to a psychiatric/neurological disease
and who were receiving any type of therapy that did
not comply with the study procedures. Among patients
who were admitted to the clinic for radiotherapy, 72
volunteers who met the study criteria were included
in the study and divided into two groups. Their therapies
were scheduled in accordance with the standard
treatment protocol of the clinic, and no nonstandard
therapies were administered. We ensured that the two
groups were divided similarly in terms of socio-economic
status, age, and sex.
We received approval from the local ethics committee
and hospital management to conduct the study,
along with informed consent from patients.
Data Collection Tools
Data were collected using a standardized demographic
data questionnaire and State Anxiety Inventory (SAI).
The medical data of patients were retrieved from hospital
records, and other data were collected by the first
author via face-to-face interviews.
Demographic data questionnaire: Demographic data
questionnaire developed by the researchers consisted
of information about sex, age, educational level, and
diagnosis.
State Anxiety Inventory: SAI developed by Spielberg
et al. measures the anxiety level at a given time, and the
Turkish version of the scale was validated by Öner and
Le Compte.[23] The 40-item inventory is composed of
two separate scales: first 20 questions measure anxiety
levels, and the remaining measure enduring anxiety levels.
SAI requires the individuals to describe how they
feel at a particular time under certain conditions and
respond to questions considering their emotions under
the circumstances. In our study, SAI was used to
measure the anxiety levels, and the items were scored
as recommended. In a validation study of the Turkish
version of SAI, Cronbach"s alpha for S-Anxiety was 0.86.
[] The anxiety levels of patients from both the groups
were evaluated a day before the therapy and after its
completion.
Procedure of musical intervention: An 11-item questionnaire
(Music Genre Preference Form) developed
by the researchers was used to determine the music
genre preferred by each participant. Three playlists of instrumental music were created in three different
genres after participants" preferences were evaluated
(Turkish folk music, Turkish classical music, and Turkish
popular music). Playlists that were 15-min long
were recorded on an Mp3 player with patients" names
on the player. Playlists were broadcasted in the therapy
room every day during radiotherapy using a stereopowered
reference monitor (Tamaha HS50M), which
reproduces the original sound by maintaining the same
power at each frequency. Patients listened to music for
12?15 min during their therapies. Over the course of
radiotherapy, patients were advised not to listen to other
music during the day.
Control group
Patients in the control group were not given any information
on music therapy during the study period to
avoid bias.
Statistical Analysis
Data were analyzed using the SPSS version 23.0 software.
In intergroup comparisons, the chi-square test
was used to compare categorical variables and t-test
and variance analysis to compare continuous variables
between dependent and independent groups. A p value
of <0.05 was considered statistically significant.
Results
Table 1 shows descriptive features of patients in the
experimental and control groups. Patients in both the
groups were similar in terms of age, sex, educational
level, and diagnosis (p>0.05). Turkish Folk Music
(TFM) was preferred by 63.9% of the participants,
Turkish Classical Music (TCM) by 33.3% of the participants
and Turkish Popular Music (TPM) by 2.8% of
the participants (Fig 1).
Table 1: Sociodemographic characteristics (n=72)
Fig 1: Distribution of music genre of choice in the experimental
group.
It was found that the anxiety levels of patients who
listened to music were lower after treatment than before
treatment, whereas those of patients who did not
listen to music were higher after radiotherapy (Table
2). In both the groups, the differences in the anxiety
levels of patients before and after treatment were statistically significant (p=0.001 and 0.003, respectively).
There were no statistically significant differences between
the anxiety levels of patients in the two groups
before treatment (p=0.071); however, the differences
between the groups after treatment were statistically
significant (p=0.036).
Table 2: Anxiety levels of patients before and after treatment in both the groups
The anxiety levels of patients according to sex, age,
educational level, and diagnosis are shown in Table
3. There was no statistically significant difference between
the anxiety levels of patients before and after
radiotherapy in terms of sex, age, educational level,
and diagnosis (p>0.05). In the experimental group, the
anxiety level was significantly lower after radiotherapy
in females (p=0.023), males (p=0.019), patients aged
46?65-years (p=0.001), primary school graduates
(p=0.010), and patients with gastrointestinal disease
(p=0.032). On the other hand, there was no statistically
significant difference in the anxiety levels in terms of
age, sex, educational level, and diagnosis. In the control
group, the anxiety level was significantly higher after
treatment in males (p=0.022), secondary+high school
graduates (p=0.042), and patients with gastrointestinal
disease (p=0.015).
Table 3: Anxiety levels of patients according to sex, age, educational level, and diagnosis (n=72)
Discussion
Although there is a lot of literature on the use of music
as a therapeutic intervention in various medical care
settings, no studies have examined the role of music
during radiotherapy in reducing the anxiety associated
with radiotherapy for cancer. Moreover, only few studies have assessed the anxiety levels during radiotherapy.
The present study aims to determine the effect of
music intervention during radiotherapy.
Research shows that music can influence a wide
range of physiological and psychological effects. These
effects can trigger the release of hormones, which can
alter body temperature by influencing the pulse rate,
breathing, sweating, and blood circulation and positively
contribute to a decrease in these effects which
enhance disease progression.[,] However, these
experiences are more likely to be positive when individuals
are exposed to the music of their choice.[]
In the present study, music genres were determined
based on patients" preferences. Music is a symbolic expression
signifying patients" psychological connections
with their past and culture. The region of origin, music
tune, lyrical or instrumental music, instruments, and
even the singer affects the preference of a listener. Studies
on music preferences demonstrated that desirable
and undesirable music stimulate different regions in
the brain [,], and that accurate determination of
listeners" preferences is decisive in therapy outcomes.
Various studies have reported that music therapy is
used during different periods of therapy. Some studies
have reported the use of music therapy before treatment
[,], some before and during treatment [],
some only during treatment [,], and some over the
course of treatment on patient"s demand.[,] In the
present study, we preferred administering music therapy
to patients during radiotherapy.
The present study found that after radiotherapy, the
anxiety levels of patients who received music therapy
were lower than those before treatment. Conversely,
the anxiety levels of patients who did not receive any
music therapy were higher after treatment than those
before the treatment. In addition, the anxiety levels of
patients who did not receive music therapy were found
to be higher after treatment even when the anxiety levels
were similar before treatment.[,]
Studies have reported significantly lower anxiety
levels after treatment in patients who receive music
therapy than in those who do not receive music therapy.[,,,,] On the other hand, other studies
have suggested that music therapy has no significant
effect on the anxiety levels.[,] Smith et al.[] reported
lower anxiety levels in patients receiving music
therapy, although the difference between the groups
was not statistically significant. In a study by Callaghan
et al., there was no significant decrease in the anxiety
levels of patients; however, patients wanted to listen to
music in future radiotherapy sessions.[]
The present study also investigated the association
between music therapy and age, sex, and educational
level in patients who received music therapy. We found
that music therapy was equally effective in both the
sexes, and there was a significant decrease in anxiety
levels in patients aged 46?64 years and primary school
graduates. However, a larger sample size is required for
further studies on these independent variables.
Limitations
The current study had some limitations. First, the data
collected from the patients were quantitative; therefore,
subjective experiences of the patients require further
investigation in terms of the effects of music therapy.
Second, no physiological variable was included in the
study; hence, the effects of music therapy on physiological
aspects need further examination. The effect
of music therapy on the anxiety levels might be clearly
demonstrated if individuals with higher anxiety levels
were included in the study. In this small, single-institution
study, both the groups were heterogeneous in
terms of cancer types and stages. Furthermore, patients
in the control group may have used other methods of
relaxation to cope with their anxiety. Another limitation
of the present study was that patients in both the
groups might have interacted with each other or with
individuals not included in the study in the waiting
room before or after treatment. This potential interaction
among the patients as well as the ongoing informal
counselling provided by the radiotherapy personnel
may have introduced bias if patients derived a significant
level of support through these interactions.
Conclusion
The present study aims to contribute to a limited number
of studies in the literature evaluating the use of
music therapy for reducing the anxiety levels in cancer
patients receiving radiotherapy. The results of the
present study suggested that listening to music during
treatment reduces the anxiety levels. In the radiotherapy
waiting room or a simulation room, music is
a relatively simple and low-cost way to ease patient
anxiety. Additional research with large samples and
adequate control of confounding variables may clarify
the full impact of formal interventions, including music.
Considering the negative effects of anxiety on the
physiological and psychosocial well-being of patients,
music therapy promises to be a method to improve the
quality of life of cancer patients.
Declarations
Disclosure of potential conflicts of interest
Informed consent: Informed consent was obtained
from all individual participants included in the study.
Disclosures Statement
The authors declare that they have no conflict of interests.
Acknowledgments: The authors have no fundings or
conflicts of interest to disclose.
Ethics Committee Approval: This study was conducted inaccordance
with local ethical rules.
Peer-review: Externally peer-reviewed.
Conflict of Interest: None declared.
References
Siegel RL, Miller KD, Jemal A. Cancer Statistics, 2017.
CA Cancer J Clin 2017;67(1):7-30.
Clark M, Isaacks-Downton G, Wells N, Redlin-Frazier
S, Eck C, Hepworth JT, et al. Use of preferred music to
reduce emotional distress and symptom activity during
radiation therapy. J Music Ther 2006;43(3):247-65.
Chen LC, Wang TF, Shih YN, Wu LJ. Fifteen-minute
music intervention reduces pre-radiotherapy anxiety
in oncology patients. Eur J Oncol Nurs 2013;17(4):436-41.
Marrs JA. Stress, fears, and phobias: the impact of anxiety.
Clin J Oncol Nurs 2006;10(3):319-22.
Pascoe S, Edelman S, Kidman A. Prevalence of psychological
distress and use of support services by cancer
patients at Sydney hospitals. Aust N Z J Psychiatry
2000;34(5):785-91.
Carlson LE, Angen M, Cullum J, Goodey E, Koopmans
J, Lamont L, et al. High levels of untreated
distress and fatigue in cancer patients. Br J Cancer
2004;90(12):2297-304.
Azuero C, Allen RS, Kvale E, Azuero A, Parmelee P.
Determinants of psychology service utilization in a
palliative care outpatient population. Psychooncology
2014;23(6):650-7.
Mackenzie LJ, Carey ML, Sanson-Fisher RW, D"Este
CA, Paul CL, Yoong SL. Agreement between HADS
classifications and single-item screening questions for
anxiety and depression: a cross-sectional survey of
cancer patients. Ann Oncol 2014;25(4):889-95.
American Psychological Association. Available at:
http://www.apa.org/topics/anxiety/index.aspx. Accessed
Jul 12, 2012.
Schreier AM, Williams SA. Anxiety and quality of life
of women who receive radiation or chemotherapy for
breast cancer. Oncol Nurs Forum 2004;31(1):127-30.
Smith EM, Gomm SA, Dickens CM. Assessing the independent
contribution to quality of life from anxiety
and depression in patients with advanced cancer. Palliat
Med 2003;17(6):509-13.
Brown LF, Kroenke K, Theobald DE, Wu J, Tu W. The
association of depression and anxiety with health-related
quality of life in cancer patients with depression
and/or pain. Psychooncology 2010;19(7):734-41.
Andrykowski MA. The role of anxiety in the development
of anticipatory nausea in cancer chemotherapy:
a review and synthesis. Psychosom Med
1990;52(4):458-75.
Pedersen AE, Sawatzky JA, Hack TF. The sequelae of
anxiety in breast cancer: a human response to illness
model. Oncol Nurs Forum 2010;37(4):469-75.
Daykin N, Bunt L, McClean S. Music and healing in
cancer care: a survey of supportive care providers. The
Arts in Psychotherapy 2006;33:402-13.
de Niet G, Tiemens B, Lendemeijer B, Hutschemaekers
G. Music-assisted relaxation to improve sleep quality:
meta-analysis. J Adv Nurs 2009;65(7):1356-64.
Covington H, Crosby C. Music therapy as a nursing
intervention. J Psychosoc Nurs Ment Health Serv
1997;35(3):34-7.
Gagner-Tjellesen D, Yurkovich EE, Gragert M. Use of
music therapy and other ITNIs in acute care. J Psychosoc
Nurs Ment Health Serv 2001;39(10):26-37.
Uyar M, Akın Korhan E. The effect of music therapy
on pain and anxiety in intensive care patients. Agri
2011;23(4):139-46.
Hilliard RE. Music therapy in pediatric oncology: a review
of the literature. J Soc Integr Oncol 2006;4(2):75-8.
Smith M, Casey L, Johnson D, Gwede C, Riggin OZ.
Music as a therapeutic intervention for anxiety in patients
receiving radiation therapy. Oncol Nurs Forum
2001;28(5):855-62.
O"Callaghan C, Sexton M, Wheeler G. Music therapy
as a non-pharmacological anxiolytic for paediatric radiotherapy
patients. Australas Radiol 2007;51(2):159-62.
Öner N, Le Compte A. State of Trouble / State Anxiety
Inventory. 2nd ed. Istanbul: Boğaziçi University Publishing;
1985.
Campbell D. The Mozart effect. New York: Avon
Books; 1997.
Bartlett D, Kaufman D, Smeltekop R. The effects of
music listening and perceived sensory experiences on
the immune system as measured by interleukin-1 and cortisol. J Music Ther 1993;30:194e209.
Brown S, Martinez MJ, Hodges DA, Fox PT, Parsons
LM. The song system of the human brain. Brain Res
Cogn Brain Res 2004;20(3):363-75.
Mitterschiffthaler MT, Ettinger U, Mehta MA, Mataix-
Cols D, Williams SC. Applications of functional magnetic
resonance imaging in psychiatry. J Magn Reson
Imaging 2006;23(6):851-61.
Rossetti A, Chadha M, Lucido D, Hylton D, Loewy J,
Harrison L. The Impact of Music Therapy on Anxiety
and Distress in Patients Undergoing Simulation for
Radiation Therapy (RT). International Journal of Radiation
Oncology 2014;90:S708-9.
Zhao P, Liang J, Shao Q, Liang F, Yuan H, You F. Intervention
effects of musical therapy to physiological
and psychological conditions in process of radiotherapy
for patients with cancer. Chin J Cancer Prev Treat
2008;15:1097-9.
Korfage IJ, Essink-Bot ML, Janssens AC, Schröder FH,
de Koning HJ. Anxiety and depression after prostate cancer diagnosis and treatment: 5-year follow-up. Br J
Cancer 2006;94(8):1093-8.
Krischer MM, Xu P, Meade CD, Jacobsen PB. Self-administered
stress management training in patients undergoing
radiotherapy. J Clin Oncol 2007;25(29):4657-
Cassileth BR, Vickers AJ, Magill LA. Music therapy
for mood disturbance during hospitalization for autologous
stem cell transplantation: a randomized controlled
trial. Cancer 2003;98(12):2723-9.
Chi GC, Young A, McFarlane J, Watson M, Coleman
RL, Eifel PJ, et al. Effects of music relaxation video
on pain and anxiety for women with gynaecological
cancer receiving intracavitary brachytherapy: a randomised
controlled trial. J Res Nurs 2015;20:129-44.
O"Callaghan C, Sproston M, Wilkinson K, Willis D,
Milner A, Grocke D, 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 Imaging
Radiat Oncol 2012;56(4):473-7.
