Music/Music Therapy

• FINAL NUMBER STUDIES INCLUDED = 10
• TOTAL PATIENTS INCLUDED IN REVIEW = 488 (62 lost to attrition)
• KEY SAMPLE CHARACTERISTICS: The frequency of intervention and type of intervention varied (Note: 10 studies of 8 different intervention foci.): 70% of the sample studies held intervention sessions once per week for a total of three to eight weeks. Participants with terminal cancer were studies either weekly or bi-weekly until death. The dance movement study held sessions two times per week for six weeks then once weekly for six weeks. One study held a music therapy session during chemotherapy.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Elder care

Depression and anxiety were shown to improve in three of the studies although the interventions were different (music therapy, art therapy, and mindfulness-based art therapy). Other psychological factors also improved: lower ratings of somatic symptoms in an art therapy study and a creative arts study, and psychiatric symptom improvement. Improvements in various measures of quality of life were reported in studies of mindfulness-based art therapy, art therapy, music therapy, creative arts therapy, and dance/movement therapies. Art therapy showed improvements in coping resources and mood states. Music therapy showed improvements in stress and anger. Creative arts therapy showed improvements in specific aspects of the Profile of Mood States (POMS) that were reported: tension-anxiety, depression-dejection, anger-hostility, and confusion-bewilderment.

Evidence reviewed in this study is inconclusive regarding effectiveness of various creative interventions.

• Selected articles using creative psychological interventions did not include writing therapy or drama therapy.  
• Meta-analysis was not possible, although rationale was clearly explained by the writers.
• Only one of the 10 articles was evaluated as having high quality; the remaining were satisfactory.
• Follow-up measures were not included in several studies.
• The number of articles included in the sample was small (n = 10).
• There appear to be discrepancies in accuracy of references to specific studies in the table: example, page 4, last paragraph indicates lack of replicated findings, whereas the table indicates otherwise.
• Specified Creative Psychological Interventions delivered by a qualified therapist were shown to improve well-being on several measures. 

The therapies were implemented by qualified therapists and were varied in nature, although not exhaustive of available therapies. The value of music, art, and movement therapies are shown to effectively reduce symptoms of anxiety and depression and improve quality of life, coping, and mood. Suggestions for further research are offered.

To examine the effects of music therapy and \"medical music\" on patients with cancer.

• Databases searched were MEDLINE, EMBASE, LILACS, CINAHL, Computer-Assisted Information Retrieval Service System (CAIRSS), and Cochrane Collaboration. The investigators also evaluated for inclusion studies listed on web sites about clinical trials or on the web sites of relevant professional organizations, those cited in journals dealing with music and music therapy, and those included in the reference lists of relevant articles.
• The investigators provided an extensive list of search terms in the report.
• Studies were included if patients, of any age, had cancer and if the studies compared music interventions to standard care, alternative interventions plus standard care, or placebo. Studies were included if they were randomized, controlled trials or incorporated quasiexperimental designs.
• Studies were excluded if they involved patients who were undergoing diagnostic procedures.

• The investigators retrieved a total of 773 studies.
• The investigators evaluated the quality of the studies according to the criteria in the Cochrane Handbook for Systematic Reviews of Interventions.

• The final number of studies analyzed was 30.
• The studies analyzed included a total of 1,891 patients.
• The range of mean patients per study was 8 to 86.
• The analyzed studies comprised multiple cancer types and age groups.

• Patients were undergoing multiple phases of care.
• The study has clinical applicability for pediatrics and palliative care.

• Findings from seven trials, regarding effect on anxiety, showed positive effects for reducing anxiety (standardized mean difference [SMD] = –0.61; 95% confidence interval [CI] [–0.97, –0.26]; p = 0.0007).
• Findings from six trials, regarding effect on pain, showed positive effects on perceived pain (SMD = –0.59; 95% CI [–0.92, –0.27]; p = 0.0003).
• The investigators noted no significant effects on depression or fatigue.
• Several studies showed that music listening and music interventions affected physical findings—for example, the studies reduced pulse rate.
• Many studies had high risks of bias, and the type, duration, and timing of the interventions varied greatly.

Music interventions appear to have beneficial effects regarding pain reduction and short-term reduction of anxiety.

• The investigators found a relatively small number of studies that examined a specific symptom or outcome.
• The interventions were very different in terms of sample types, timing, and duration; therefore, synthesizing the findings was difficult. 
• Most studies had small sample sizes and high risks of bias.

Music therapy and listening to music may be helpful means of reducing anxiety and perceived pain, and these interventions can have an effect of moderate size. The effects may be relatively short-lived, and the evidence is somewhat weak in terms of study design. However, listening to music has no risks for patients, can be easy to implement, and is an intervention that patients can do themselves. Nurses can suggest that patients use this approach to help manage pain and anxiety.

STUDY PURPOSE: To assess and compare the effects of music therapy and music medicine interventions for psychological and physical outcomes in people with cancer

TYPE OF STUDY: Meta-analysis and systematic review

• FINAL NUMBER STUDIES INCLUDED = 39 studies in meta-analysis, 52 studies in qualitative review
• TOTAL PATIENTS INCLUDED IN REVIEW = 3,313
• SAMPLE RANGE ACROSS STUDIES: 8–182
• KEY SAMPLE CHARACTERISTICS: Various tumor types and age groups during multiple phases of care

PHASE OF CARE: Multiple phases of care

The standard mean difference for fatigue in the music intervention group was 0.38 (7 studies, 253 participants, p = 0.03). Anxiety was reduced with music (13 studies, 1,028 patients, mean difference = –8.54, p < 0.0001). Results also showed a positive effect for depression (7 studies, 723 participants, standard mean difference = –0.4, p = 0.02).

Music interventions also had a small to moderate beneficial effect on fatigue, anxiety, and depression.

• Mostly low quality/high risk of bias studies
• High heterogeneity

Music therapy may have a small to moderate effect on fatigue, anxiety, and depression.

STUDY PURPOSE: To evaluate the effects of music on symptoms in patients with cancer

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Ovid, PsycARTICLES, and PsycINFO (2002–2012)

KEYWORDS: neoplasms, cancer, and music or melody

INCLUSION CRITERIA: Used a music intervention in patients with cancer; quantitative methods; quasi-experimental or experimental design; reported statistical information to describe results; evaluated effects on anxiety, depression, pain, or fatigue

EXCLUSION CRITERIA: Qualitative design, case studies, or single-group studies

TOTAL REFERENCES RETRIEVED = 367

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Quality assessment with adapted Cochrane guidelines; the k value between reviewers was 0.9.

• FINAL NUMBER STUDIES INCLUDED =  21–17 for anxiety, 8 for depression, 6 for pain, and 5 for fatigue
• SAMPLE RANGE ACROSS STUDIES = 32–126

APPLICATIONS: Pediatrics, palliative care

For anxiety, music therapy had a moderate and significant effect with an effect size of -0.553 (Hedges; g) (95% CI -0.716, -0.398). There was significant heterogeneity in the sample. For depression, music therapy moderately and significantly reduced depression with an effect size for each study ranging from -0.151 to -0.787. Results were homogenous. Five of eight studies showed significant effects. For pain, music had an overall effect size of -0.656 (Hedges' g) (95% CI -1.016 to about -0.295), showing moderate-level effects on pain. There was significant heterogeneity among studies. For fatigue, music therapy had a small effect size of -0.422 (Hedges' g) (95% CI -0.669, -0.175). Results were homogenous. Studies were seen to be of good quality. Results of subgroup analysis suggest that music therapy is more effective in adults than children and more beneficial when the music is selected by the patient rather than the therapist.

This analysis shows that music interventions can reduce anxiety, depression, pain, and fatigue in patients with cancer with small-to-moderate effect sizes.

In several areas, there was high heterogeneity. Sample sizes, timing, and types of music interventions varied substantially, and, in most, the impact was evaluated immediately after the music intervention. Whether music has ongoing effectiveness with continued use or any lasting effect on the symptoms assessed is unclear.

Music interventions can be a good adjunctive and non-medication therapy that is of benefit in reducing anxiety, depression, pain, and fatigue in patients with cancer. The most beneficial ways and times to use music therapy are unclear. Nurses can suggest that patients use listening to music as part of self-care and can advocate for use of music as a low-risk intervention to ameliorate acute anxiety and pain symptoms.

To evaluate the effects of listening to music and poetry on pain, depression, and hope

Patients were randomly selected for inclusion and then randomly assigned to listen to instrumental music or poetry readings on a MP3 players or to a control group. Therapies were offered for three days and for 30 minutes at a time. Study measurements were obtained before and after the intervention on day 1 and again on the last day. Listening was monitored. The daily variations in pain of the music and poetry group were compared to those of the control group.

• N = 65   
• AGE RANGE = 18 years to older than 60 years
• MALES: 28%, FEMALES: 72%
• KEY DISEASE CHARACTERISTICS: Various tumor types
• OTHER KEY SAMPLE CHARACTERISTICS: Of the participants, 38% were receiving NSAIDs and weak opioids, and 43% were receiving NSAIDs and strong opioids.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Brazil

Randomized, parallel-group, prospective trial

• Visual analog scale (VAS) for pain
• Beck Depression Inventory (BDI)
• Herth Hope Scale

Listening to music was associated with improvement in pain (p < 0.001) and depression (p = 0.004). Listening to poetry was associated with improvement in pain (p < 0.001), depression (p = 0.001), and hope (p = 0.009). Individuals with either intervention had improvement in pain compared to the controls (p < 0.001), but no difference was observed in other outcomes.

Listening to music or poetry reading may help in the management of pain and depressive symptoms.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (no blinding)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement/methods not well described
• Although measurements were conducted at several time points during the study, the actual measurement used for reporting was not specified.
• No information was provided on the reason for patient hospitalization. 
• No information was provided regarding analgesic dosages or changes during the study period.

Listening to music or poetry may be beneficial to patients in the management of pain and dealing with depressive symptoms. Flaws in this study limit the strength of these findings; however, these are low-risk and low-cost interventions that might be beneficial. The type of music and poetry would likely affect the results for various patients.

To examine the effect of listening to music on comfort from chemotherapy symptoms (pain, tiredness, nausea, depression, anxiety, drowsiness, lack of appetite, not feeling well, and shortness of breath) for patients undergoing chemotherapy.

Intervention group: Each member was given a portable mp3 player (with double earphones) containing music prepared by Turkish Psychological Association (TPA) containing 30 minutes of relaxation wave sounds with harp and violin. Participants were asked to listen to the music in the chemotherapy unit before treatment. Instructions were to listen to the music at least three times weekly in keeping with recommendations from TPA. 

Summary: Participants were given a pre-loaded mp3 player with instructions to listen for 20 to 30 minutes once a day for a minimum of three days per week and to record specific observations: dates and times of symptom experiences and music listening.

• N = 70; 35 in each group   
• AGE: Mean = 54.51 years (SD = 10.35) 
• MALES: 47.1%  
• FEMALES: 52.9%
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Lung cancer, 31.4%; breast cancer, 32.9%; colon cancer, 12.8%; other cancer, 22.9%
• OTHER KEY SAMPLE CHARACTERISTICS: Sequential selection: First 35 to control group, next 35 to intervention group to avoid inter-group influence by association or talking.

• SITE: Single site   
• SETTING TYPE: Multiple settings, such as listening in clinic and at home
• LOCATION: Public hospital in Tekirdağ, Turkey

PHASE OF CARE: Active anti-tumor treatment

Quasi-experimental with two groups (intervention and control) using pre-/post-test measures

• Patient Information Form: Self-developed by researchers for demographics (age, sex, educational level, marital status, profession, and diagnosis). Delivered to each participant for completion at home. 
• Patient Observation Form: For the control group, a chart for recording chemotherapy symptoms, dates, and communication with the researcher. For the intervention group, a form for recording days of treatment, duration of treatment, dates and times of symptoms, and music listening. 
• Edmonton Symptom Assessment System (ESAS): Used to measure nine of the most commonly occurring chemotherapy symptoms (pain, tiredness, nausea, anxiety, drowsiness, lack of appetite, not feeling well, depression, and shortness of breath) using a number (scale not clear) to indicate severity. 
• General Comfort Questionnaire (GCQ): 48-item Likert-type scale with three levels and four dimensions of comfort, ranging from 1 (low comfort) to 4 (high comfort). Includes reverse coding for negative items. Scale was adapted to Turkish language and context 2008.

There was no significant between-group difference at baseline. The statistically significant differences in the intervention group related to music listening were for pain, exhaustion, nausea, anxiety, lethargy, lack of appetite, and not feeling well. However, no significant differences were found for depression or shortness of breath. 

There were statistically significant differences between groups for comfort measures: general comfort, physical comfort, psycho-spiritual comfort, and sociocultural comfort. All intra-group (within-group) differences were statistically significant for comfort measures.

Listening to specified music for specified time periods was positive for chemotherapy symptoms: pain, exhaustion (fatigue), nausea, anxiety, lethargy, lack of appetite, and not feeling well; and on measures of general comfort, physical comfort, psycho-spiritual comfort, and sociocultural comfort. 

There were no positive effects on depression or shortness of breath.

• Small sample (< 100)
• Measurement/methods not well described; unclear how numbers scale was used to indicate symptom levels for common symptoms of chemotherapy treatment.
• Findings not generalizable
• Other limitations/explanation: Self-report of symptoms and listening adherence by patients. Small sample in one site of one country with one type of music–suggesting application to just one small group.

Music listening may diminish symptom severity in patients undergoing chemotherapy. Music therapy should be considered as an important element of holistic treatment for patients who have a cancer diagnosis and chemotherapy.

• To determine the impact of music therapy sessions on outcomes of pain, depression, anxiety, shortness of breath, and mood
• To understand which patient characteristics and goals and music therapist interventions had an effect on study outcomes

Data was collected on admitted palliative medicine patients receiving music therapy from September 2000 to May 2012. A board-certified music therapist (MT-BC) on the unit conducted music therapy sessions with individual palliative medicine patients and family members present. Multiple goals may have been addressed at a single session, using a variety of live patient-preferred musical interventions. Interventions included six main categories—music listening, verbal/cognitive participation, vocal participation, physical participation, verbal/emotional participation, and music-assisted relaxation. Symptom evaluations from patients included pre- and post-session severity of pain, depression, anxiety and shortness of breath. Data collected on patients included standardized music therapy assessment, elements of standardized music therapy, clinical note, patient related information, patient goals for the session, interventions used by the music therapist, symptom evaluations from patients, behavioral evaluations from the therapist, music used, patient and family member reactions, and narratives.

• N = 239   
• AGE: Average = 60 years; median = 61 years; range = 20-89 years
• MALES: 33.1%  
• FEMALES: 66.9%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: All palliative patients; diagnoses include lung cancer, hematologic cancer, breast cancer, gastrointestinal cancer, gynecologic cancer, ASL, sickle cell disease, cardiovascular, chronic pain/RSD/fibromyalgia, liver disease/cirrhosis, ESRD, AIDS, bowel obstruction, multiple sclerosis 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were included if they were 18 years or older, having at least one patient-reported rating of pain, depression, anxiety, shortness of breath, or mood before and after the music therapy session.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: The Cleveland Clinic (Ohio)

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

This is a retrospective study of data collected on palliative medicine patients admitted from September 2000 to May 2012 who participated in music therapy sessions.

• Patient-reported severity of pain, depression, anxiety, and shortness of breath were all rated on a scale from 0 to 10 that was obtained pre- and post-music session.
• Patient-reported mood rated on a scale from 0 to 4 based on the Rogers Happy/Sad Faces Assessment Tool that was obtained pre- and post-music session.
• Music therapist-reported scores on facial expression, body movement, and vocalization based on a three-point scale before, during, and after the music therapy session based on the Nursing Assessment of Pain Intensity and Riley Infant Pain Scale.

Statistically significant reduction improvement in pre- and post-session mean scores were reported for all measurements (p < 0.001) except body movement (p = 0.16). However, the percentage of patients who achieved the clinical significant threshold ranged from 0.7% to 66.2%. Outcomes with the highest percentage of patients with clinically relevant improvement were mood (66.2%), vocalization (58.7%), and facial expression (55.6%). Only 12.3% of patients experienced any clinically relevant improvement. 96% of participants had an overall positive verbal response to the session versus 4% of participants that experienced an ambivalent or no verbal response. Patients who listed pain, depression, anxiety, shortness of breath, or mood as a goal for music therapy achieved the most improvement in these symptoms. Vocalization seemed to have significantly improved when verbal/emotional intervention was used and when distraction was a goal of music therapy. There was no impact on patient demographic or cancer diagnosis on outcomes.

Music therapy does appear to have a positive effect on symptoms of dyspnea and should be considered as an adjunct to current standard interventions. However, more research is needed to determine the degree of clinical benefit of music therapy in the improvement of dyspnea, as well as its cost-effectiveness and duration effect.

• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Use of observational behavioral data (such as the music therapist-reported outcomes) could be biased as it relies on the therapist’s opinion. Therefore, inter-rater reliability of the rating scales was not assessed to account for multiple interpretations of various patient behaviors. Authors “arbitrarily” decided that a change of 2 points on a 10-point rating scale and a change in 1 point on a 4-point rating scale would be considered clinically relevant improvement of symptoms. The study results do not take into consideration the effects of session interruptions, patients with severe pain or high anxiety, actively dying, or those who had fallen asleep. Study also does not capture cost-effectiveness or duration effect of music therapy.

Music therapy should be considered as an adjunct to current standard interventions for dyspnea.

To study the effect of music on anxiety and depression

Patients listened to music for at least 20 minutes daily for three consecutive days. Music was provided through headphones and consisted of light music selected by experts. Study measurements were done daily after the intervention.

• N = 60   
• AGE: Range = 18-65
• MALES: 57.2%  
• FEMALES: 42.8%
• KEY DISEASE CHARACTERISTICS: 54% had soft tissue tumors; others were bone cancer and leukemia. The majority in both groups had stage IV disease.
• OTHER KEY SAMPLE CHARACTERISTICS: 63% had less than high school education. Baseline HADS score was slightly over 14 in both groups.

• SITE: Single site   
• SETTING TYPE: Not specified    
• LOCATION: India

Two-group, non-random, quasi-experimental

Hospital Anxiety and Depression Scale (HADS)

There was no significant change in HADS scores in the control group. HADS scores declined significantly over the three days of the music group (p < 0.001)

Listening to music was associated with short-term reduction in symptoms of anxiety and depression.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Key sample group differences that could influence results

Listening to music is a low-risk intervention that may be of benefit in managing symptoms of anxiety and depression.

Evaluate the effects of music therapy in addition to standard treatment in patients undergoing high-dose chemotherapy (HDC) plus autologous stem cell transplantation (ASCT) on quality of life, anxiety, and depression.

For the intervention group, a trained music therapist administered therapy two times per week for at least 20 minutes, based on the individual needs of each patient established prior to therapy, and each session included a debrief or aftertalk. Quality of life was assessed prior to therapy, weekly during treatment, at discharge, and again three months later.

• N = 66   
• AGE: Mean = 50 years (all older than 18 years)
• MALES: 43 
• FEMALES: 23 
• CURRENT TREATMENT: Chemotherapy, other
• KEY DISEASE CHARACTERISTICS: Malignancies treated with HDC plus ASCT with an expected inpatient stay of two weeks or longer
• OTHER KEY SAMPLE CHARACTERISTICS: No evidence of participation in other clinical trials, immobilization, brain metastasis, experiencing a severe psychotic episode, or having major depression. Seventy percent of patients in the intervention group had multiple myeloma versus 40% in the control group

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Department of Oncology and Hematology of the University Medical center Hamburg-Eppendorf, Germany

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care

Randomized controlled trial

EORTC QLQ-C30, HADS-D, Karnofsky performance score

Quality of life declined less in the intervention group (8.1 points) versus control (11.4 points), difference between groups was not significant (p = 0.394)

Because of multiple limitations of study, the authors declared their findings to be preliminary.

• Small sample (< 100)
• Baseline sample/group differences of import
• Selective outcomes reporting
• Measurement validity/reliability questionable
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: 29 of the 66 patients involved in the study were assessed in follow up (high dropout rate); extracted data from the large number of patients with multiple myeloma to report positive effects of music therapy, but when this data was considered, results were no longer significant.

Opportunity for further research

To examine effects of music therapy and progressive muscle relaxation (PMR) training on depression and anxiety in Chinese patients with breast cancer 

Patients randomly were assigned to the intervention group (which received the music and PMR intervention) or a usual care group after a radical mastectomy. To avoid contamination, intervention and control patients were placed in different inpatient areas. Music therapy involved listening to music via headphones connected to an MP3 player for 30 minutes twice per day. This began within 48 hours after surgery. Patients selected their preferred music. PMR training was conducted on the second postoperative day. Training was conducted twice per day for 30 minutes until discharge. Patients were encouraged to do PMR and music listening exercises together. Patients in the control group received the usual postoperative nursing care only. Study measures were obtained the day before surgery and the day before hospital discharge. Data collectors were blinded to group assignment.

• N = 170  
• MEAN AGE = 47.01 years (SD = 9.5 years)
• FEMALES: 100%
• KEY DISEASE CHARACTERISTICS: Most had modified radical mastectomy and 89% had chemotherapy immediately after surgery

• SITE: Single-site    
• SETTING TYPE: Inpatient    
• LOCATION: China

• PHASE OF CARE: Active antitumor treatment

Randomized, controlled, single-blinded trial

• Zung Self-Rating Depression Scale (SDS)
• State-Trait Anxiety Inventory (STAI)

Analysis showed that there was a significant reduction in anxiety and depression over time alone (p < .001) as well as by group (p < .001), and there was a significant interaction between group and time (p = .0009). Depression scores declined an average of 7.2 points in the intervention group and 4.6 points in the control group. Anxiety scores declined an average of 16 points in the intervention group and 11 points in the control group. Hospital stay time was significantly lower in the intervention group (p < .001). Hospital stay length was shorter in the intervention group.

The findings of this study suggest that the combination of PMR and listening to music was helpful in reducing anxiety and depression in women after mastectomies.

• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Other limitations/explanation: No information was provided regarding other potential confounders such as postoperative complications, pain levels, etc. that could influence reported outcomes. Data collection was conducted via face-to-face interview, and although it was stated that data collectors were blinded, it is not clear where the data collection took place. If it took place in the hospital, data collectors could deduce group assignment because of the different locations in the hospital. This study was of Chinese women, so applicability to other groups is not known. It is not clear in the report whether all sessions of the intervention were guided by the investigators or done by the patients on their own. It is not clear how, if supervised by investigators, the patient could listen to the PMR training if they also were listening to music via headphones.

Listening to music and using progressive muscle relaxation may have a positive impact on anxiety and depression in patients postoperatively. These are low-risk, low-cost interventions that may be beneficial. The findings of this study showed that those who had the intervention also had shorter hospital stays. There is insufficient evidence to determine the real impact of this intervention on duration of hospitalization; however, these findings suggest that this area deserves further exploration.

To study the effects of music therapy on depression in female patients with breast cancer after radical mastectomy; to study how music therapy affects duration of hospital stay  

Subjects were randomly assigned to a music or usual-care group (control). Investigators collected data on the day before radical mastectomy (pretest), the day before hospital discharge (first post-test), and at the second and third hospital admissions for chemotherapy (second and third post-tests). Different chemo intervals meant that the second and third post-tests were between 14 and 28 days; the mean time was 18.6 days (SD = 7.4 days). Total intervention time involved the hospital stay after radical mastectomy (mean 13.6 days [SD = 2 days]) and the two chemotherapy periods (the mean time of each period was 8.9 days (SD = 7.1 days). The experimental group received an introduction to music, and participants selected preferred music. Each participant listened to his or her choice of music through headphones connected to an MP3 player. Participants listened to music twice a day, 30 minutes each time. Investigators did not offer music to the control group.

• The sample was composed of 120 participants, 60 in each group.
• The age range of participants was 25–65 years.
• All the participants were female.
• All the participants had breast cancer that required radical mastectomy.
   

• Single site
• Medical college
• Xi’an, Shaanxi, China
   

• Phase of care: active treatment
• Clinical applications: late effects and survivorship
   

Randomized controlled trial with repeated measures

• Chinese version of the Zung Self-Rating Depression Scale (ZSDS)   
• General questionnaire, for the collection of demographic data

• Investigators retrieved 450 validated questionnaires. The rate lost to follow-up was 12.5%.
• Clinical data and demographic data about age, education, income, marital status, and quality of spousal relationship revealed no significant baseline differences between the two groups (P > 0.05).
• Before radical mastectomy, the mean depression score of all participants was 37.19 (SD = 6.30); 36 participants (30%) suffered from depression symptoms. At baseline, data revealed no statistical difference in depression between groups. Post-test depression scores did demonstrate significant differences between the two groups (F = 39.13, P < 0.001; F = 82.09, P < 0.001).
• The depression scores of both groups trended downward during follow-up periods, but the score curve of the experimental group was lower than that of the control group (p < 0.001).
• Postradical mastectomy, the mean duration of hospitalization, experimental group, was 13.62 days (SD = 2.04 days); mean duration of hospitalization, control group, was 15.53 days (SD = 2.75 days). This difference was significant (P < 0.001).

Postmastectomy, depression scores of the experimental group were lower than those of the control group, and duration of hospital stay was shorter for patients receiving music therapy. However, lack of data regarding actual use of music therapy by patients and lack of information regarding patients’ health status and other types of treatment preclude recommendation of music therapy without further study.

• Data were self-reported.
• Double-blind methodology was not used because of the specificity of the intervention.
• Investigation was from a quantitative aspect only; subjective experiences were not studied.
• Subjects with extensive radical mastectomy played a small part in this trial.
• The percentage lost to follow-up was high. 
• The study had a potential testing effect as a result of repeated measurement.

When caring for patients with breast cancer who are suffering from mood disturbance, nurses should select interventions whose evidence of mood-disturbance reduction is greater than the evidence of effect that listening to music presents. However, listening to music is a low-risk, low-cost intervention that might be helpful to some patients.

4,900 references were identified that were published between January 1, 1990 and December 31, 2013. 203 articles were included in the final review although only 174 were referenced. Grades used and reported here were A: recommended, high certainty of benefit, B: recommended, high certainty of moderate to substantial benefit, D: recommends against use, moderate to high certainty of no net benefit, and H: recommends against use, moderate to high certainty that harms outweigh benefits.

Interventions for specific symptoms that had strong recommendations for or against use were:

• Anxiety: Music therapy during RT and chemotherapy sessions, meditation, and yoga for patients undergoing therapy (B-level recommendation)
• Depression: Mindfulness-based stress reduction for patients undergoing radiotherapy, relaxation, and yoga (level A recommendation); massage and music therapy (level B)
• Fatigue: Energy conservation (level B)
• CINV: Acupressure and electroacupuncture in addition to antiemetics (B level)
• Neuropathy: Acetyl L carnitine was not recommended because of harm (H level).
• Radiodermatitis: Aloe vera and hyaluronic acid cream were not recommended as standard therapy because of lack of effect (D level).

It appears that only specific types of interventions were included, and there are numerous types of integrative or complementary interventions that were not considered in this review. The findings considered were limited to women with breast cancer. Quality rating of evidence was not discussed individually.

These guidelines provided an evidence-based evaluation of various integrative therapies in women with breast cancer. This set of interventions is not all-inclusive; however, it does provide some guidance to clinicians and others regarding evidence strength in these areas as assessed by this specific study group.