02.06.

17

Kind of blue
- a systematic review and meta-analysis of music interventions in cancer treatment
by
Margrethe Langer Bro1,2
Kira Vibe Jespersen3
Julie Bolvig Hansen4,5
Peter Vuust3
Niels Abildgaard6
Jeppe Gram7
Christoffer Johansen8,9
Abstract: word count = 250
Full text: word count = 3324
1
The Danish National Academy of Music, Odense, Denmark
2
Institute of Regional Health Science, University of Southern Denmark, Odense, Denmark.
3
Center for Music in the Brain, Institute of Clinical Medicine, Aarhus University/The Royal
Academy of Music, Aarhus/Aalborg, Denmark
4
Departments of Sports Science and Clinical Biomechanics, The University of Southern
Denmark (SDU)
5
Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital,
Copenhagen, Denmark
6
Department of Haematology, Odense University Hospital, Denmark
7
Department of Endocrinology, Hospital of Southwest Denmark
8
Oncology Clinic, Rigshospitalet, University of Copenhagen, Denmark
9
Unit of Survivorship, Danish Cancer Society Research Center, Copenhagen, Denmark
Corresponding author: Margrethe Langer Bro. University of Southern Denmark, J. B.
Winsløws Vej 19, 5000 Odense, Denmark. E-mail: mlbro@health.sdu.dk. Tel +45 2231 0140

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1002/pon.4470

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ABSTRACT

Objectives Music may be a valuable and low-cost coping strategy for cancer patients. We
conducted a systematic review and meta-analysis to identify the psychological and physical
effects of music interventions in cancer treatment.

Methods We included randomized, controlled trials with adult patients in active cancer
treatment exposed to different music interventions versus control conditions. Qualitative
studies and systematic reviews were excluded. We identified a total of 2624 records through
two systematic searches (June 2015, September 2016) in PubMed, Scopus, EMBASE,
Cinahl, Web of Science, Cochrane and PsycINFO and used Risk of Bias Assessment, GRADE
and Checklist for Reporting Music-Based Interventions to evaluate the music applied and
quality of the studies. We conducted meta-analyses using Review Manager (version 5.3).
PROSPERO reg. no. CRD42015026024.

Results We included 25 RCT´s (N=1784) of which 20 were eligible for the meta-analysis
(N=1565). Music reduced anxiety (SMD -0·80 [95% CI -1·35 to -0·25]), pain (SMD -0·88
[95% CI -1·45 to -0.32]), and improved mood (SMD -0·55 [95% CI -0·98 to -0·13]).
However, studies were hampered by heterogeneity with I2 varying between 54% and 96%.
Quality of the studies ranged from very low to low. The most effective mode of music
intervention appeared to be passive listening to self-selected, recorded music in a single
session design.

Conclusions Music may be a tool in reducing anxiety, pain and improving mood among
cancer patients in active treatment. However, methodological limitations in the studies
carried out so far prevent firm conclusions.

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BACKGROUND

Music is increasingly offered as an adjunct to cancer treatment in the clinical setting [1-7].
Cancer affects all aspects of life, both in terms of somatic, psychological and social
dimensions, and these multi-dimensional problems are so immense and complex that they
require interdisciplinary approaches to meet the patient’s needs [8]. Music is observed as a
potential source for wellbeing for patients coping with a cancer diagnosis, during treatment
and in the aftermath [1-7].

Previous reviews of music, given at different time points of cancer treatment, have shown
that both somatic and psychological symptoms are positively affected by music [1-7].
However, these reviews applied different inclusion criteria for studies included. For example
the first and recently updated Cochrane meta-analysis included both randomized and quasi-
randomized studies [1]. Moreover, paediatric studies were not excluded from their analysis.
Consequently, inclusion of such ambiguous data may reduce the usefulness and impact of
their conclusions. One of the subsequent reviews published, included 17 studies in Chinese,
not available in English [3]; further one previous review conducted a screening strategy
focusing solely on anxiety by using the PEDro-scale to measure methodological quality,
which resulted in only four studies for meta-analysis [5]. Finally, a review published in 2014
included 21 RCTs and quasi-experimental studies across all age groups [6]. However, more
importantly, these reviews did not consider the qualities of the music, the patient´s musical
background or musical preferences as part of the evaluation of the effects of the music
intervention [1-7]. For example, it remains to be investigated how key elements of musical
structure such as tempo, rhythm, pitch, frequency spectrum and duration or type of music
influence the efficacy of the music provided.

In this review and meta-analysis we aim to clarify how music interventions affect
psychological and physical symptoms in patients undergoing active cancer treatment by
including information on 1) the involvement of the patients undergoing the intervention, e.g.
passive listening or active participating, 2) how live versus recorded music influences the
effect, 3) whether music is applied one or more times; e.g., single- or multiple sessions, and
finally 4) how intervention content; e.g., repertoire, tempo, rhythm, harmony and tone
influence the outcome under study.

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METHODS

Search strategy

Two authors, (MLB and KVJ) conducted a systematic search in PubMed, Scopus, EMBASE,
Cinahl, Web of Science, Cochrane and PsycINFO and independently screened all titles and
abstracts evaluating full text articles for inclusion. Any disagreements were discussed and
clarified in consensus with a third author (CJ). Reference lists of reviews were hand-searched
for additional references. The research dates were June 26, 2015 and September 1, 2016 for
update search. The selection process is summarized in the Prisma flow diagram (Fig. 1) and
the search terms were: PubMed search strategy:
1 Neoplasms (MESH)
2 Cancer OR oncolog* OR Malignan* OR Neoplasm* OR Carcinoma* OR Tumo*
3 #1 OR #2
4 Music (MESH)
5 Music therapy (MESH)
6 Music*
7 #3 AND #4 OR #5 OR #6s

Inclusion and exclusion criteria

We included all randomized controlled trials examining music intervention exposure of
adults (+18 years) in active cancer treatment. Thus, exclusion criteria were music treatment
during diagnostic procedures, palliation in the terminal phase of cancer as well as art therapy.
Studies eligible for inclusion were peer reviewed original reports, published in English or
German and accessible in full text. The interventions to be studied included music-listening
before, during or after cancer treatment consisting of the following methods: Passive listening
or active participating in live or pre-recorded music versus no music intervention, or music
combined with other modalities such as movements, relaxation techniques, imagery versus
control condition. The interventions were either self-administered by the patient or
administered by musicians, music therapists or research personnel. The distinction between
passive listening and active participating was chosen from the patients role in the music
intervention.

If sufficient data was available, we included the following outcomes for the meta-analysis:

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anxiety, distress, quality of life, depression, relaxation, fatigue, nausea and pain.

Risk of bias assessment

In accordance with the recommendations of the Cochrane Handbook [9], a quality assessment
of the included articles was performed independently by two review authors (MLB and KVJ),
using the risk of bias assessment by Cochrane (Fig. 2*).

Quality assessment of studies. Description of music intervention

We used the GRADE scoring system, adopted by the Cochrane Collaboration [9], to rate the
overall quality of the evidence (Table. 3*). Further, we adapted the Guideline for Music-
based Interventions developed by Robb et al, [10] by adding information regarding the
Patients’ Perspective; e.g., musical background, preference and hearing ability (Table 1, full
version*). Musical background is defined as musical engagement and training, musical
culture and frequency of music listening.

Statistical analysis

We used Covidence [11] to extract the predefined outcomes from the included trials. For each
eligible study, mean (m) and standard deviation (SD) or standard error (SE) and relevant
demographic information were extracted. If data was not available, the authors of the trial
were contacted. Meta-analyses were conducted for all outcomes where one or more trial
reported data (Fig. 3a) (Fig. 3b-3j*). We calculated the pooled estimate by using the random
effects model in Review Manager 5.3. When multiple outcomes measures reported the same
outcome, standardized mean differences (SMDs) were used. Where only one study or a single
outcome measure was reported we used mean differences (MDs). Negative effect size
indicated a beneficial effect of the intervention. According to Cohen 1988 [9], an effect size
of 0.2 was considered a small effect, an effect size of 0.5 medium and an effect size of 0.8
was considered to be large.

RESULTS

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The literature search revealed 2860 records. Of these, 102 full-texts were assessed for
potential eligibility and 77 were excluded for various reasons (Fig. 1). The remaining 25
articles with a total of 1784 participants met the inclusion criteria for this review, and 20
studies reported sufficient data for the meta-analysis. Characteristics of included studies are
shown in Table 2. Sample sizes ranged from 18 to 129 patients. Recorded music was applied
in 17/25 studies, whereas live music was offered in 8/25 studies. Numbers and duration of
music interventions varied from 1 to 8 sessions and 15-60 minutes, respectively, and multiple
sessions were conducted within a three-day to 15 months schedule. Music intervention was
applied during surgery (n=5) [12 - 16], chemotherapy (n=7) [17 - 23], radiotherapy (n=4) [24
- 27], other procedures (n=5) [28 – 32] and hospitalization (n=4) [33 - 36].

Passive listening or active participating

Patients were passively listening to music in 15/25 studies; 13 studies applied recorded music
studies [12 - 16, 20, 23, 24, 27, 31 – 34] and 2 live music [22, 36]. Recorded music offered a
self-reflecting inner musical experience, whereas live music added a shared musical moment
together with the musician(s). Patients were active participating in the music intervention, in
10/25 studies; four recorded music studies [19, 21, 26, 28] and six live music studies [17,18,
25, 29, 30, 35]. Out of these, one three-armed study compared active participation with
passive listening versus control [28]. Recorded music offered a supportive dimension in
terms of verbal relaxation techniques, guided imagery and mood matching techniques,
whereas live music covered mutual and engaging involvement from singing along, clapping,
or tapping feet to improvising into a creative musical process. In all studies with active
participation, music therapists conducted the targeted interventions.

Psychological outcome
Anxiety (Fig. 3a, 4a*) Twelve studies focused on anxiety-reduction, mostly through recorded
music 11/12. Out of these, nine studies were eligible for meta-analysis showing an overall
statistically significant anxiety reduction (SMD -0·65 [CI 95%-1·20,-0·11]) [12, 14, 16, 17,
21, 26, 27, 31, 32]. The intervention design varied, e.g., 8/12 passive listening, 7/12 single
sessions. Keywords for music-choice were familiar, soothing, predictable and relaxing music.

Mood (Fig. 4b, 4b*). Six studies investigated mood [18, 22, 25, 28, 29, 36] and four were
eligible for meta-analysis showing an overall statistically significant effect (SMD -0·55 [CI

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95% -0·98, -0·13]) [22, 25, 28, 29]. Patient-preferred live music was applied in five studies,
patients were actively engaged in four studies and multiple sessions were offered in 4 studies.

Other psychological primary outcomes were measured in six trials without showing an
overall statistically significant effect; depression (Fig. 3c*) [15, 26] (SMD -0·89 [CI 95% -
2·92, 1·14]), spirit (Fig. 3d*) [35] (MD -2·69 [CL 95% -5·57, 0·19], distress (Fig. 3e*) [18,
26] (SMD -0·25 [CI 95% -1·03, 0·52]), Quality of Life (Fig. 3f*) [18, 23] (SMD -0·21 [CI
95% -0·55, 0·14] and relaxation (Fig. 3g*) [17] (MD 1·23 [CI 95% 0·42, 2·04]. Patients were
actively involved in four studies, and most studies used multiple session designs. Three
studies offered live music and three studies applied recorded music.

Physical outcomes
Pain (Fig. 3h, 4c*). Eight studies were eligible for meta-analysis. Except one study [26], pain
was significantly reduced by music (SMD -0·88 [CI 95% -1·45 to -0·32])[12, 13, 22, 29, 31,
33, 34]. Overall, the intervention design was similar across studies; e.g. passively listening in
6/8 studies and single sessions in 5 studies. Besides two studies [26, 29] applying patient
preferred live-music, the researchers had specific considerations on which recorded music
style, genre, volume and tempo, that could trigger pain-relief; e.g., slow (60-80 beats per
minute), sustained melodic quality and controlled volume and pitch [34], relaxing,
instrumental music [33] and classical, easy listening, inspirational new age music [12].

Other physical outcomes. Fatigue (Fig. 3i*) was measured in three studies [17, 26, 30]
without showing an overall statistically significant effect (SMD -0·22 [CI 95% -1·08, 0·63]).
In these studies, patients were actively involved by singing along [17], attending relaxation
techniques [26] or verbal interaction between songs [30]. Nausea (Fig. 3j*) was measured as
primary outcome in a three-armed study [23] without showing statistically significant effect
(MD 3·92 [CI 95% -2·22, 10·07]).

Overall, 16/25 trials found a significant effect on the primary outcome. The majority of
studies offering passively listening to music showed larger effect on primary outcome (11/15
studies) than those conducting active participating (5/10 studies). One may anticipate that
treatment modalities of the cancer disease; e.g., radiation therapy, surgery or chemotherapy

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would influence the outcome. However, we found no correlation when considering this
stratification across all music intervention studies included.

Musical choice and content

Overall, patient-selected music was widely used (20/25 studies) across categories of studies.
Further, most sessions (23/25 studies) were individualized according to the patient’s needs. In
some studies, patients selected music from four or five categories of music styles and genres;
[20, 34, 36] or from a general playlist provided by the investigator, a musician or music
therapist (13, 14, 24]. In these studies, authors targeted the musical content; e.g., tempo,
melodic quality, repertoire and instrumentation to the patient’s needs during treatment [19,
21, 28, 31, 34]. In other studies, the repertoire was selected on the basis of the patient’s
musical preference and found on internet radio [16, 32], music media library [15], live music
list [22], or in collaboration with a music therapist [26]. In one study, patients brought their
own favourite CDs [27]. In order to accommodate the patient’s cultural background and
identity, traditional music was applied in several studies; e.g., Celtic melodies [22], Chinese
folk music [15], Taiwanese folk songs/Buddhist music [22, 34]. Singing with guitar
accompaniment was widely used in other studies [17, 29, 30, 35] and patients were
encouraged to sing-along. Flute, lyre and keyboard were offered in one study [18], and
patients were encouraged to improvise on percussion instruments. Headphones were used in
12 studies in order to distract from machinery buzz, improve concentration and audio quality,
whereas loudspeakers were used in three studies [16, 26, 31]. Only three studies reported data
on music played during the music intervention [24, 31, 34].

According to Table 1 (full version*), Intervention Theory and Schedule Delivery were well
described in most studies, whereas information about Music Repertoire was inadequate in
11/25 studies. Half of the studies excluded patients with hearing problems 12/25, whereas
only few investigated the patient’s musical background [22, 27, 34] preference [19, 24, 34]
and setting of the intervention [18, 21, 22, 32, 35].

Risk of Bias Assessment and quality of evidence:

As shown in Fig. 2*, 19/25 trials used the most preferable randomization procedure [12 -16,
18, 21 - 27, 29 - 32, 34, 35], and selective reporting seemed to be at low risk [12, 15, 16, 18,
20 - 29, 31, 32, 34 - 36]. However, only six trials reported concealed allocation in the
outcome assessment and data analysis procedure [17, 23, 27 – 30] and 23/25 were rated as

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high risk in blinding of participants and personnel due to the characteristics of intervention
[13 - 32, 34 - 36]. Blinding of outcome assessment was not adequately described in the
majority of studies [12 - 14, 16, 17, 19 - 21, 23 - 36] as well as a lack of outcome data, which
were apparently incomplete in 8/25 studies [13, 14, 18, 19, 23, 25, 28, 35].
The overall quality of the evidence was rated from low to very low according to GRADE
(Table 3*) due to severe study limitations, inconsistency and imprecision.

DISCUSSION

Our systematic review and meta-analysis suggest that music can relieve anxiety and pain for
patients in active cancer treatment. However, the studies are hampered by small sample sizes
[12, 17 - 20, 22 - 26, 28 - 30, 32, 33, 35, 36], risk of underpowered studies [23-27, 30, 32],
heterogeneity in the interventions applied and overall low - to very low-rated quality of the
studies.

In studies investigating pain, single-sessions were applied in most studies [12, 29, 31, 33, 34]
except three [14, 23, 26], and patients were passively listening in six out of eight studies. In
these studies, intervention theory, design and content of the music were connected with the
patient´s music choice. However, the studies were small and the validity as well as reliability
of effect measures varied. Conversely, a significant decrease in a majority of anxiety-studies
was supported using STAI-scales [12, 14, 16, 20, 21, 31], large sample sizes [14, 16, 21, 31]
and partial coherence between intervention theory, exposure and musical content [12].

With regard to tempo [17] and music applied [16, 17] information was sparse, and three
articles investigating anxiety, pain and depression as primary endpoints, respectively, were
published based on the same material [13 - 15]. Overall, fewer than 100 patients were
included in studies before 2010, and there was no increasing tendency over time in
conducting power calculations.

The most well documented mode of music intervention is passively listening to recorded
music in a single session design. The majority of studies offering passively listening to
music showed significant outcomes (11/15 studies) compared to those conducting active
participating (5/10 studies). The passive listening trials were more transparent with regard
to design, musical content, and most studies used recorded music. Further, no live music

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studies reported information on tempo, content and the quality of the actual music played;
e.g., instruments in tune, musical communication between musicians, acoustics or decibel
[17, 18, 22, 25, 29, 30, 35, 36]. Several multiple-session studies (6/12) failed to show a
significant difference in primary outcome than single session studies (9/13). Attrition rates
were significantly higher in these studies, duration of the interventions was longer
compared to single-session studies, and the timing of frequency seems imprecise. On the
other hand, it could be argued that multiple-sessions provide more clinically relevant data
compared to single-sessions excluding short term and transient effects in patients exposed
for the first time to a new treatment modality. Overall, information on intervention
content; e.g., tempo (3/25 studies), rhythm, harmony (12/25 studies) and tone were sparse
and it was therefore difficult to deduct how these factors might influence the outcome of
studies. Additionally, there was no coherence between intervention theory, exposure and
outcome [12, 23, 24, 32]. The lack of focus on the patient’s musical background and
preference in the majority of studies [12 - 21, 23 - 26, 28 - 33, 35, 36] could impair the
results and discourage individualized and targeted music interventions. This is supported
by recent brain research showing that the brain’s processing of music is strongly affected
by the individuals’ musical background and competence [37].

Music is not just music. The understanding of the nature of musical sound is vital in order to
meet the individual cancer patient´s needs and hereby achieve the desired effect. One of the
reasons for this is that music has an arousal-regulating effect [38, 39]. Slow musical tempo is
found to decrease heart rate and blood pressure, while faster music increases these
measurements [40]. Further, especially self-selected favourite music can create positive
emotions, activate memories, affect heart rate, blood pressure and respiration and decrease
levels of pain [41, 42] and cortisol [43, 44]. Therefore, music tends to be a beneficial tool for
relief of anxiety and pain and for stress reduction with direct implication for cancer treatment
[45 – 48, 49]. This is essential knowledge in the understanding of how music interventions
may work.

We find that individualized balanced considerations regarding rationale, content exposure of

music are needed rather than former demands for developing standardized procedures; e.g.,
optimal duration, frequency and the most appropriate musical style for music interventions. It

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is impossible to make uniformed methods in this complex field. It has been suggested that a
universal perspective of music covers the fact that across cultures upbeat; high pitch and
dissonant music will increase arousal-levels whereas slow, relaxing and low intensity music
will decrease arousal-levels [39]. The individual perspective covers identity social association
that musical environment has great impact on how we respond to music and which music we
prefer [39]. The cultural perspective covers the musical culture that e.g., understanding of
underlying structures, scales and tonal language. This creates a cultural recognition and opens
up for fulfilment of expectation and surprise [50].

Clinical implications:
Music is a valuable tool that is easy to use in the clinical setting. More high-quality
randomized controlled trials are needed to assess the effectiveness of music in cancer
treatment; however, such interventions would be meaningless unless the patient´s musical
perspective is included in their design

Limitations and strengths:

This is the first review comparing design, musical content, musical background, preference
and involvement of the patient with outcome-results. The fact that patient-preferred, recorded
music in a single session design seems to be the most well documented mode of intervention
gives a in-depth view on where to improve in design and transparency in multiple-session
studies applying live music. Bradt el al used broader inclusion criteria and they found that
multiple session music therapy studies were either as effective or more effective than music
medicine studies on QoL[1].

Despite a thorough approach following the Cochrane recommendations, our outcome-results

did not conclude differently from a number of previous reviews on this area illustrating the
overall limitations in design. However, as we exclusively focused on RCT´s addressing music
intervention to the specific physical and physiological problems in active cancer treatment,
we believe that our review gives a comprehensive and more precise view on the actual status.

A possible limitation of our study might be not restricting the studies for meta-analysis based
on quality of evidence. However, we included al eligible studies in order to reveal the overall
quality of music interventions in active cancer treatment.

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Another limitation could be that the lack of information regarding content, duration and
frequency of some of the music interventions prevented us from carrying out sensitivity
analysis.

Conclusion
Music may be a tool in reducing anxiety, mood and pain among cancer patients in active
treatment. However, lack of transparency in music repertoire and methodological limitations
in the studies carried out so far refrain firm conclusions. When using the guidelines by Robb
et al, (2011), Gebauer et al, (2014) and adding the patient´s musical perspective; e.g.,
background, preference and hearing ability, the quality of future studies might increase. One
may anticipate that music might provide recovery of self-identity, meaning and coherence in
life and hereby add musical empowerment to the everyday life of the individual cancer
patient.

* online material

Acknowledgements

We would like to thank research librarian Peter Everfelt for his assistance with the search process.

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Figure Legends

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Fig. 1: Study selection process

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Fig. 2*: Risk of Bias Assessment

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Fig. 3A: Forest plot of comparison: music intervention vs standard care, for adults in active
cancer treatment, outcome: Anxiety (A)

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This article is protected by copyright. All rights reserved.
Fig. 3B-J*: Mood (B), Depression (C), Spirit (D), Distress (E), Quality of Life (F),
Relaxation (G), Pain (H), Fatigue (I) and Nausea (J)

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This article is protected by copyright. All rights reserved.
Fig. 4A-C*: Funnel plot with anxiety (A), mood (B) and pain (C) outcome

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AUTHOR INTERVENTION INTERVENTION CONTENT INTERVENTION PATIENT´S
[Ref. No.] THEORY SCHEDULE PERSPECTIVE
DELIVERY
1) Rationale for MUSIC Music Person Intervention 1) Single/ multiple 1) Musical
the choice of music Repertoire Delivery selecting the Strategy session background
Form, tempo, rhythm, Method music 1) PASSIVE 2) Duration 2) Musical
melody, harmony, 1) LIVE 1) Pre-selected listening 3) Frequency preference
voicing, tonality, lyrics MUSIC by investigator 2) ACTIVE 3) Hearing Ability
Musician 2) Patient participating
Instrument selected from Involvement
2) limited set
RECORDED 3) Patient Single Multiple
MUSIC selected from session session
Equipment: own preference
headphones vs. or collection
loudspeakers (CD)
Volume/ 4) Tailored
Decibel level based on patient
assessment
Zimmermann 1) Yes Instrumental tapes of 10 RECORDED 2) PASSIVE 30 min 1) Yes 3) Ex
1989 different musical styles. MUSIC (CD) 2) Yes
[33] Halpern antifrantic Headphones
(relaxing/ self-healing) Volume:
music if patients had no Controlled by
musical preference. patient
Smith 1) No Rock & roll, big band, RECORDED 3) PASSIVE 30 min 1) No 3) Ex
2001 country, western, MUSIC (CD) Frequency: 2) Yes
[24] classical, easy listening, Headphones daily for
Spanish or religious Volume: No min 5
music. 4-7 tapes were info weeks
available in each
category.
Cassileth 1) Yes No info. LIVE MUSIC 4) ACTIVE 20-30 min 1) No 3) No info
2003 Music therapist The patients x5 2) No
[25] Instrument: No musical Frequency:

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 info preferences During a
and clinical median of
problems 10 days
dictated the
content of
the therapy.
Clark 1) Yes No info RECORDED 4) ACTIVE 90 min 1) No 3) No info
2006 MUSIC Relaxation tape. 2) No
[26] (Cassette tape) techniques, Length of
Headphones imagery, sessions
Volume: No Positive self- unknown
info talk Frequency:
2-4 times
per week
for 4-5
weeks.
Hanser 1) Yes No info. LIVE MUSIC 4) ACTIVE 3x45 min 1) No 3) No info
2006 Music therapist 1st Session: Frequency: 2) No
[18] Flute, lyre, Patient Up to 15
guitar, preferred weeks
keyboard, live music,
dulcimer, voice relaxation
suggestions
2nd Session:
Patient
preferred
live music,
singing
improvising
with
percussion
instruments.
3rd Session:
Patient
preferred
live music,
song writing

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Ferrer 2007 1) Yes Patient preferred LIVE MUSIC 3) ACTIVE 20 min 1) No 3) No info
[17] favourite songs and Music Singing 2) No
music styles. therapist? along,
Singing with clapping,
classical guitar tapping their
accompaniment feet
Burns 2008 1) Yes Light classical and new RECORDED 4) ACTIVE 45 min x 8 1) No 3) No info
[19] age music was chosen MUSIC (CD) Education Frequency: 2) Yes
based on the patient´s Equipment: and Twice a
musical preferences, Playback experience. week
emotional state and machine Relaxation, patients
energy level. Volume: No music were
info imagery encouraged
techniques to do
exercises
at least
once a day
during up
to 4 weeks
hospital
stay.
Bulfone 1) Yes Pre-taped musical RECORDED 2) PASSIVE 15 min 1) No 3) Ex
2009 themes; New age, nature MUSIC 2) No
[20] music, film sound Earphones by
tracks, Celtic melodies, Walkman
classical music. Volume: No
Specific recordings info
informed.

Huang 1) Yes 4 tapes available: Folk- RECORDED 2) PASSIVE 30 min 1) Yes 3) No info
2010 tunes and Buddhist MUSIC (CD) 2) Yes
[34] hymns, harp and piano Headphones
music. Sedative music, Volume:
without lyrics, sustained Controlled
melodic quality,
controlled pitch, 60-80

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 BPM

Binns-Turner 1) No 1-4 types of music; RECORDED 2) PASSIVE 60 min 1) No 3) Ex

2011 classical, easy listening, MUSIC (IPod) 2) No
[12] inspirational, new age Earphones
(also controls)
Volume: max
70 dB
Li 2011 1) Yes 202 music pieces RECORDED 2) PASSIVE 30 min 1) No 3) Ex
[13] available; classical MUSIC (Mp3) twice a day 2) No
Chinese folk music, Headphones Frequency:
popular world music, Volume: From
Chinese relaxation Controlled by 1stday
music. patients after
surgery
until 3rd
chemo-
therapy
Li 2011 1) Yes 202 music pieces RECORDED 2) PASSIVE 30 min 1) No 3) Ex
[14] available: Chinese MUSIC (Mp3) twice a day 2) No
classical folk music, Headphones Frequency:
famous world music, Volume: From 1st
Chinese relaxation Controlled by day after
music. patients surgery
until 3rd
chemo-
therapy
Lin 2011 1) Yes 1. Three-step GIM RECORDED 1) ACTIVE 60 min 1) No 3) Ex
[21] process: Preparation MUSIC (CD) Guided 2) No
Period (10 min): Songs Headphones relaxation
of the Pacific Volume: 55-70
Deep Relaxation dB
Period (12 min):
meditation-relaxation-
tape with verbal
instructions. Light
music, Forest Piano

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 with sounds of nature
Music Listening
Period (38 min): Violin
Rain, Aroma Lavender.
2. Data from Relaxation
group was not included
in this review.
Zhou 2011 1) Yes 202 music pieces RECORDED 2) PASSIVE 30 min 1) No 3) Ex
[15] available: classical MUSIC (Mp3) twice a day 2) No
Chinese folk music, Headphones Frequency:
popular world music, Volume: From 1st
Chinese relaxation Controlled by day after
music. patient surgery
until 3rd
chemo-
therapy
OCallaghan 1) Yes No info. Patient brought RECORDED 3) PASSIVE Not 1) Yes 3) Ex
2012 music to their first MUSIC reported 2) No
[27] treatment. Loudspeaker
Volume: At
reasonable
level
Cook 1) Yes No info. 3-8 songs were LIVE MUSIC 4) ACTIVE 15-30 min 1) No 3) No info
2013 chosen from MT´s Music therapist Autonomy x3 2) No
[35] repertoire based on Instrument: support and Frequency:
patients preferred music Acoustic active 3 days in
style guitar, voice involvement line
Ratcliff 1) Yes 1. ¶ ISO-group: The ISO & UM 4) ISO-group ISO-Group: 50 min x 4 1) No 3) No info
2013 music therapist created groups: 2) UM group ACTIVE Frequency: 2) No
[28] two 30-minute CDs. RECORDED Mood- no info
Tempo was modulated MUSIC (CD) matching
from fast to slow Equipment: No therapy
(relaxing CD) or slow to info UM Group:
fast (energizing CD) Volume: No PASSIVE
based on patient-choice info
and mental state with
regard to BMP

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 2. II UM group: The
mental health therapist
created two CDs based
on patient-choice of
energizing and relaxing
songs with no regard to
order and BPM.

Vachiramon 1) Yes No info. Patients chose RECORDED 2) PASSIVE 15-60 1) No 3) Ex

2013 a musical genre, artist, MUSIC min 2) Yes
[16] or track, which was Loudspeaker but not
entered into internet Volume: No tracked
radio. info
Burrai 1) Yes Patients chose 5-6 LIVE MUSIC 2) PASSIVE 30 min 1) Yes 3) Ex
2014 musical pieces from a Musically 2) No
[22] playlist of 100 famous skilled nurse
national/international Instrument:
pieces. Different styles Saxophone
(relaxing, cheerful,
lively) and genres (pop,
classical, film, folk,
jazz).
Fredenburg 1) Yes No info. Patient LIVE MUSIC 4) ACTIVE 30 min 1) No 3) No info
2014 preferred live music. Musician: Structure, 2) No
[29] Investigator involvement
Instrument: and
Steel-string autonomy
guitar, voice support
Moradian 1)Yes (grp I) Grp 1: Nevasic RECORDED 1) PASSIVE 30 min. 1) No 3) Ex
2014 1) No (grp II) programme MUSIC (CD) Frequency 2) No
[23] Grp 2: No info. Pre- Equipment: varied
selected music. Headphones
Volume: No
info
Rosenow 1) Yes No info. Patient- LIVE MUSIC 3) ACTIVE 45 min 1) No 3) No info
2014 preferred live music. Musician: ISO 2) No
[30] Researcher Verbal

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 Instrument: interaction
Guitar, voice between
songs
Yates 1) Yes No info. Patient- LIVE MUSIC 3) PASSIVE 20-30 1) No 3) No info
2015 preferred live music. Musician: No Therapeutic min 2) No
[36] info interaction
Instruments:
No info
Zengin 1) Yes Turkish classical, slow, RECORDED 1) PASSIVE 30 min 1) No 3) Ex
2013 instrumental, relaxing MUSIC 2) No
[31] music Equipment:
Music system
Volume: No
info
Lawson 1) No No info. Patients chose RECORDED 2) PASSIVE 60 min. 1) No 3) No info
2016 from a pre-existing MUSIC 2) No
[32] radio playlist including Equipment:
a variety of music Apple iPad
genres and eras mini
Volume: No
info

¶ ISO: Mood-matching music therapy

II UM: Unstructured music group
Table 1: Music intervention characteristics

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Author Country Sex N/ Diagnosis Treatment Intervention groups Outcome measures Effect of intervention
[Ref in Stage of type Live (LM) or Primary and secondary Significant or non-
no] analys cancer recorded music (RM) significant (NS) difference
is vs between pre- and post test
Standard care (SC)

Zimme USA Bot 40/40 Oncology Pain 1. RM Primary: Pain (MPQ) Primary: Decrease
rmann h Metastatic manageme 2. SC Secondary: VAS Secondary: NS
* disease nt Post-test measured after intervention
[33]
Smith* USA Bot 44/42 Oncology During 1. RM Primary: Anxiety (STAI) Primary: NS
[24] h Stage radiation 2. SC Post-test measured after 1 week of
unknown therapy interventions
Cassilet USA Bot 69/62 Haematologic During 1. LM Primary: Mood. POMS-short form Primary: NS
h h al high-dosis 2. SC Measured over whole in-patient stay. Secondary: Improvement
[25] Stage radiation Secondary: Mood. POMS-short form.
unknown therapy Measured before and after first MT and
with every 3rd day of inpatient stay.
autologous
stem cell
transplanta
tion
Clark USA Bot 68/63 Oncology Radiation 1. RM Primary: ND Secondary: NS
[26] h Stage I-IV therapy 2. SC Secondary: Anxiety & Depression
with or (HADS), Treatment-related distress &
without Pain (NRS), Fatigue (POMS).
surgery Post-test measured at mid-point and at the
and end of RT
chemother
apy
Hanser USA F 70/42 Metastatic Chemother 1. LM Primary: Psychological distress (HADS). Primary: NS
[18] breast cancer. apy and 2. SC Quality of life (FACT-G Secondary: Improvement
Stage IV other Spirituality (FACIT-sp)
therapies Secondary: Mood, Relaxation, Comfort
(VAS).

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 Heart rate and blood pressure
Psychological post-test measured after 6
weeks and 6 months. Physical post-test
measured after interventions.

Ferrer USA Bot 50/50 Unknown During 1. LM Primary: ND Secondary:

[17] h Stage Chemo- 2. SC Secondary: 1-2: Reduction
unknown therapy 1-2: Anxiety & Fear (VAS) 3-4: NS
3-4: Worry & Level of comfort (VAS) 5. Increase
5. Level of relaxation (VAS) 6. Decrease
6. Fatigue (VAS) 7. NS
7. Systolic blood pressure (SBP) 8. Increase
8. Diastolic blood pressure (DBP) 9. NS
9. Heart rate (all post-test scores)
Post-test measured after intervention

Burns* USA Bot 49/30 Acute Intensive 1. RM Primary: Anxiety STAI-YI (STAI-YU) Primary: NS
[19] h leukemia myelosupp 2. SC (and Feasibility**) Secondary: NS
Stage resive Secondary: Affect (PANAS)
unknown chemother Fatigue (FACIT-F)
apy Anxiety (STAI-YI)
Time of measuring post-test unclear

Bulfone Italy F 60/60 Breast Waiting 1. RM Primary: Anxiety (STAI) Primary: Reduction
* Stage I-II for 2.SC Post-test measured after intervention
[20] adjuvant
chemother
apy
Huang Taiwan Bot 129/12 Various Cancer 1. RM Primary: Cancer related Pain. (dual VAS Primary: Decrease
[34] h 6 Stage I-IV pain 2. SC (rest) scale -sensation and stress) Distress: Decrease
Waitlist-control Post-test measured after intervention Sensation: Decrease
design

Binns- USA F 30/30 Breast Mastectom 1. RM Primary: ND Secondary:

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Turner Stage y 2. SC plus earphones Secondary: 1. Decrease
[12] unknown Pre- and without music 1. Mean arterial pressure (MAP) 2. NS
post- 2. Heart rate HR 3. Reduction
operative. 3. Anxiety (STAI) 4. Decrease
4. Pain (VAS)
Post-test measured after procedure
Li‡ China F 120/10 Breast Radical 1. RM Primary: Pain (SF-MPQ) Primary: Decrease
[13] 5 Mixed stages mastectom 2. SC 3 post-test measured day before discharge
y and on the day for first & second
chemotherapy.
Li‡ China F 120/10 Breast After 1. RM Primary: Anxiety (STAI) Primary: Reduction
[14] 5 Mixed stages radical 2. SC 3 post-test measured day before discharge
mastectom and on the day for first & second
y chemotherapy.
Lin Taiwan Bot 123/98 Various During 1. RM Primary: Anxiety (STAI) Primary: Reduction -
[21] h Stage I-IV Chemother 2. Relaxation Secondary: Emotion (EVAS). Heart rate, greatest with MT.
apy therapy** skin temperature, night sleep Secondary: Reduction -
3. SC Post-test measured after intervention greatest with MT.
Significant increase in skin
temp. in MT and RX
groups.

Zhou‡ China F 120/10 Breast Radical 1. RM 1. Depression (ZSDS Chinese version) 1. Reduction
[15] 5 Mixed stages mastectom 2. SC 2. Duration of hospital stay 2. Shorter
y Three post-tests measured day before
discharge and on the day for first and
second chemotherapy.

O- Germany Bot 100/97 Various Radiation 1.RM Primary: Anxiety (STAI) Primary: NS
Callahg h Stage therapy 2.SC Post-test measured after intervention
an unknown
[27]
Cook USA Bot 34/17 Haematologic Hospitalize 1. LM Primary: Meaning of life, peace & faith. Primary: Faith: Increase
[35] h al & d cancer 2. Waitlist control Spirituality (FACIT-sp) Peace: Increase.
Oncology patients group Post-test measured three days after final
Stage intervention.
unknown

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Ratcliff USA Bot 90/68 Leukemia Recoverin 1. RM Primary: Mood (POMS-SF) Primary: Improvement.
[28] h Lymphoma g from 2. RM Secondary: Long-term effect on POMS- Best effect in Grp. 2.
Others hematopoi 3. SC SF. Health-related QOL. (FACT-G) Secondary: NS
Stage etic stem Bone Marrow Transplant subscale
unknown cell (FACT-BMT)
transplanta Cancer-related symptoms: (MDASI)
tion Post-test measured after final intervention
Vachir USA Bot 100 Skin Before and 1. RM Primary: Anxiety (STAI) Primary: Reduction
amon h Stage during 2. SC Secondary: Anxiety (VAS) Secondary: Reduction
[16] unknown Mohs Post-test measured after intervention
surgery
Burrai Italy Bot 52 Metastatic & During 1.LM Primary: Mood (VAS), Primary: Improvement
[22] h non- chemother 2.SC Secondary: Pain (VAS), Systolic and Secondary: NS
metastatic apy diastolic BP, pulse rate, glycaemia, Oxygen saturation: Increase
Stage I-II oxygen saturation
Time of measuring post-test unclear.

Freden USA Bot 34/32 Haematologic Recoverin 1. LM Primary: ND Secondary:

burg h al g from 2. Wait-list control Secondary: 1. Increase in positive
[29] Stage bone group 1. 10-item Positive and Negative Affect affect. Negative affect: NS.
unknown marrow Schedule (I-PANAS-SF) 2. Reduction
transplanta 2. Pain (10-point Likert-type-scale)
tion Post-test measured after intervention
Moradi Iran F 99 Breast During and 1. Nevasic audio Primary: Nausea (The Rhodes INVR) Primary: NS
an Stage II-III after program Secondary: Quality of life (EORTC-QLQ- Secondary: NS
[23] chemother 2. RM 30 & BR23).
apy 3. SC Daily diary: nausea & vomiting

Roseno USA Bot 18/18 Leukemia Recoverin 1.LM Primary: Fatigue (BFI) Primary: NS
w h Stage g from 2. SC Post-test measured after intervention
[30] unknown bone Waitlist-design
marrow
transplants
Yates† USA Bot 26/22 Oncology Post- 1. LM Primary: Mood (QMS) Primary: Improvement in
[36] h Stage surgical 2. SC Post-test measured after intervention one (relaxed) out of 6
unknown (drowsy, depressed.
aggressive, confused,

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 clumsy) mood states

Zengin Turkey Bot 100 Oncology Undergoin 1. RM Primary: ND Secondary:

[31] h Stage g port 2. SC Secondary: 1-2: Reduction
unknown catheter 1. Serum cortisol and adrenocorticotropic 3-5: Decrease
placement hormone
procedure 2. Anxiety (STAI)
3. Pain VAS)
4. Heart rate
5. Systolic and diastolic BP
Post-test measured after intervention
Lawson USA Bot 39 Haematologic Recoverin 1. Art making ** Primary: ND Secondary:
[32] h al g from 2. RM Secondary: 1-4: NS
Mixed stages bone 3. SC 1. Symptoms of treatment (TRSC)
marrow 2. Anxiety (STAI)
transplants 3. Systolic and diastolic BP
4. Temperature, Pulse and Respiration

LM=live music. RM=recorded music. SC=standard care. NS=not significant. ND=not determined. MPQ=McGill pain questionnaire. VAS=visual analogue scale. STAI-Y1,
STAI-Y2=state-trait anxiety inventory. POMS=profile of mood state. HADS=hospital, anxiety, depression scale. NRS=numeric rating scale. FACT-G=functional assessment
of cancer therapy-general. FACIT-sp=functional assessment of chronic illness therapy-spiritual wellbeing. SBP=systolic blood pressure. DPB=diastolic blood pressure.
PANAS=Positive and negative affect schedule. FACIT-F=functional assessment of chronis illness therapy-fatigue scale. MAP=mean arterial pressure. HR=heart rate. SF-
MPQ=short-form of McGill Pain Questionnaire includes VAS & PPI=pain intensity. ZSDS=self-rating depression scale. POMS-SF=profile of mood state. FACT-
BMT=functional assessment of cancer therapy - bone marrow transplant subscale. MDASI= Anderson symptom inventory. I-PANAS-SF=positive and negative affect
schedule short-form. The Rhodes INVR=index of nausea, vomiting, retching. EORTC-QLQ-30=European organization for research and treatment of cancer quality of life
questionnaire. EORTC-BR23=…for breast cancer women. BFI=brief fatigue inventory. QMS=quick mood scale. TRSC: Therapy-Related Symptoms Checklist
* not included in meta-analysis results because SD was not given
† not included in meta-analysis. Yates reported sub score raw data to author, however no overall score is available in QMS.
‡ Li, Li and Zhou are included in meta-analysis with one data-set only. They published data from identical data-set.
**Not included in this review

Table 2 Study demographics

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