The findings of this three-arm, randomized controlled trial showed that music interventions reduced anxiety and nausea compared to standard care, regardless of the type of music intervention, in cancer patients receiving CT for the first time. This suggests that the positive neurological effects of music in areas such as cognitive function and emotion may be useful in controlling adverse symptoms of cancer patients. Therefore, the results obtained from our study suggest that the development of music algorithms and the implementation of music therapy protocols during CT sessions, especially starting from the initial CT process, may be authorized for cancer patients.
We investigated the calming and anxiolytic effects of music in our study by choosing relaxing and peaceful compositions (60–66 and 60–80 bpm). We aimed to see the effect of both cultural and familiarity characteristics of music by choosing TCM, a more preferred music genre in Turkish culture, as an intervention arm of our study. Culturally familiar music is recommended as part of an effective music intervention since it is more likely to encourage the individual's initial engagement and evoke positive memories [36]. In the other intervention arm of the study, we preferred an RM based on nature sounds that are less familiar compared to TCM but have the ability to overcome language, social and cultural barriers. Although culturally unfamiliar music is perceived as strange by the individual at the initial stage, it is reported that it can affect different regions in the brain and provide stronger cortical activity and neurological interaction compared to more familiar music [37, 38]. Adherence to the music sessions of at least 60 minutes in length was high. According to the feedback we received from our patients who completed the music session properly, the acceptability of both music interventions was high. However, some patients also expressed a desire to listen to their preferred music, which suggests that future study designs may take into account the patient's favorite or preferred music genres.
The results of the primary and secondary outcomes on anxiety, nausea, and satisfaction level indicate a prospect of benefiting from the music intervention regardless of the genre. The STAI (STAI-T and STAI-S), which assessed the patients' level of anxiety, showed homogeneous moderate anxiety in all groups at baseline. Anxiety was significantly lower in both RMG and TCMG compared to the CG (standard care) after the intervention. Previous studies reported that music effectively reduces anxiety in cancer patients [23, 24, 39, 40], which is in line with the results of our study. However, although the patients in the TCMG had higher levels of satisfaction and listening time, the TCMG and RMG did not differ significantly in controlling anxiety. This may have been because the sample consisted of patients newly diagnosed with cancer and patients receiving CT for the first time. A cancer diagnosis can be an unexpected life-changing event for patients and their families. Patients may experience various reactions such as shock, denial, confusion, sadness, anger, guilt, and resignation when informed about the diagnosis. In addition to emotional turmoil, patients often have to quickly acquire new information to cope with the new situation, form treatment plans together with healthcare professionals, and understand their care options [41, 42]. This process can further increase patients' anxiety levels. Therefore, patients might be inclined to need to relax and calm down regardless of the type of music. As a matter of fact, in open-ended questions in which patients reported their thoughts about music therapy during the CT process and their expectations from healthcare professionals, they stated that they were highly satisfied with the music, but they needed more information about the disease process and wanted different non-pharmacological options to be offered in addition to music.
In addition to physiological stimuli, psychological stimuli, such as anxiety caused by the stress response, may cause some unpleasant GI symptoms such as nausea and vomiting [43]. In light of this theory, we aimed to evaluate the nausea that might be caused by anxiety associated with the new cancer diagnosis and the first CT experience. In the three groups, nausea, as measured by a 10-point VAS, was low at the baseline, and there was no significant difference between the groups. Compared to the baseline, there was a decrease in post-intervention nausea in the RMG and TCMG, whereas there was an increase in the CG. Considering that all patients in the study sample received premedication treatment with strong antiemetics before CT, the fact that patients still reported nausea, even at a low level, suggests that it may be related to anxiety. Therefore, there might have been a linear decrease in the level of nausea associated with the decrease in anxiety in the intervention groups. However, it should be kept in mind that the majority of patients in this study received CT protocols such as carboplatin and AC, which are known to cause moderate to high levels of nausea [44]. In order to better clarify the effect of music on anxiety-related nausea, it may be recommended that future studies continue music therapy in the subsequent treatment sessions and evaluate patients by increasing the number of music sessions.
Although we did not examine the effects of multi-session music on the patients’ response, our findings suggest that at least one hour of music therapy may improve anxiety and nausea outcomes in patients receiving CT for the first time. However, further studies comparing session frequency, music duration, or music preferred by patients are needed to clarify the potential benefits of music.
Limitations
This study has limitations that should be considered. The study was conducted in a single center, only with patients receiving CT for the first time. Therefore, it may not be generalized or representative. Further multicenter studies with a larger sample size are needed to confirm the findings of the current study. The use of self-reported measures to assess changes in patient outcomes might have led to social desirability and recall bias. The study evaluated the short-term effects of listening to music and did not include any follow-up for ongoing CT cycles. Blinding of patients and practitioners was not possible due to the nature of the study. The music in the current study was selected by the researchers and was not intended to provide the patient's preferred music, which has been reported to be more effective in some studies. Future studies may offer participants more music options according to their preferences. Another limitation is the lack of selection criteria or stratification parameters based on other subgroups, such as being more or less anxious, CT protocol, or cancer stage, in case a different confounding effect was present. As in other trials for complementary therapies, adjunctive treatment designs (i.e., administration of complementary therapies with standard drugs) limit the ability to isolate the effects of the complementary intervention from the overlapping effects of pharmacological intervention.