Music Therapy Reduces Radiotherapy-Induced Fatigue in Patients With Breast or Gynecological Cancer: A Randomized Trial

Abstract

Purpose:
To investigate the influence of music therapy on the reduction of fatigue in women with breast or gynecological malignant neoplasia during radiotherapy, since it is one of the most frequent side effects of this type of treatment, and may interfere with self-esteem, social activities, and quality of life.

Experimental design:
Randomized controlled trial (control group [CG] and music therapy group [MTG]) to assess fatigue, quality of life, and symptoms of depression in women undergoing radiotherapy using the Functional Assessment of Cancer Therapy: Fatigue (FACT-F) version 4, Functional Assessment of Cancer Therapy-General (FACT-G) version 4, and Beck Depression Inventory in 3 separate times, namely, during the first week of radiotherapy, on the week of the intermediary phase, and during the last week of radiotherapy. Individual 30- to 40-minute sessions of music therapy with the presence of a trained music therapist were offered to participants.

Results:
In this study, 164 women were randomized and 116 (63 CG and 53 MTG) were included in the analyses, with mean age of 52.90 years (CG) and 51.85 years (MTG). Participants in the MTG had an average of 10 music therapy sessions, totaling 509 sessions throughout the study. FACT-F results were significant regarding Trial Outcome Index ( P = .011), FACT-G ( P = .005), and FACT-F ( P = .001) for the MTG compared with the CG.

Conclusions:
Individual music therapy sessions may be effective to reduce fatigue related to cancer and symptoms of depression, as well as to improve quality of life for women with breast or gynecological cancer undergoing radiotherapy. Further well-designed research studies are needed to adequately determine the effects of music therapy on fatigue.

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https://doi.org/10.1177/1534735418757349https://doi.org/10.1177/1534735418757349
Integrative Cancer Therapies
2018, Vol. 17(3) 628 –635
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DOI: 10.1177/1534735418757349
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Research Article
Introduction
Fatigue is one of the most commonly experienced cancer
symptoms, affecting 70% to 100% of the people undergoing
cancer treatments.1,2 Cancer-related fatigue (CRF) is
defined by the European Association for Palliative Care as
a subjective symptom of tiredness, weakness, or lack of
energy.3 The National Comprehensive Cancer Network
describes CRF as a subjective, distressing, and persistent
symptom of physical, emotional, and/or cognitive tiredness
or exhaustion related to the disease or its treatment.4
In 2012, 41% of all new female patients of neoplasia
worldwide had breast or gynecological cancer.5 A review
study demonstrated that fatigue is a frequent symptom in
patients undergoing radiotherapy and may become a factor
that limits or even prevents the continuity of treatment.2
757349ICTXXX10.1177/1534735418757349Integrative Cancer TherapiesAlcântara-Silva et al
research-article20182018
1Federal University of Goias (UFG), Goiânia, GO, Brazil
2Centro Brasileiro de Radioterapia, Oncologia e Mastologia (CEBROM),
Goiânia, GO, Brazil
3Instituto Integrado de Neurociências (IINEURO), Goiânia, GO, Brazil
4Araújo Jorge Hospital, Associação de Combate ao Câncer em Goiás
(ACCG), Goiânia, GO, Brazil
5Associação de Pais e Amigos dos Excepcionais (APAE), Goiânia, GO, Brazil
6Federal University of Rio de Janeiro (UFRJ), Brazil
Corresponding Author:
Tereza Raquel Alcântara-Silva, Universidade Federal de Goiás, Campus
II, Samambaia, Avenida Esperança, s/n, Campus Universitário, 74690-900
Goiânia, GO, Brazil.
Email: terezaraquel.mas@gmail.com
Music Therapy Reduces Radiotherapy-
Induced Fatigue in Patients With Breast or
Gynecological Cancer: A Randomized Trial
Tereza Raquel Alcântara-Silva, MT, PhD1,
Ruffo de Freitas-Junior, MD, PhD1, Nilceana Maya Aires Freitas, MD, PhD2,
Wanderley de Paula Junior, MS3, Delson José da Silva, MD, PhD1,4,
Graziela Dias Pinheiro Machado, RN3, Mayara Kelly Alves Ribeiro, MT, MS5,
Jonathas Paiva Carneiro, MT6, and Leonardo Ribeiro Soares, MD1
Abstract
Purpose: To investigate the influence of music therapy on the reduction of fatigue in women with breast or gynecological
malignant neoplasia during radiotherapy, since it is one of the most frequent side effects of this type of treatment, and
may interfere with self-esteem, social activities, and quality of life. Experimental Design: Randomized controlled trial
(control group [CG] and music therapy group [MTG]) to assess fatigue, quality of life, and symptoms of depression
in women undergoing radiotherapy using the Functional Assessment of Cancer Therapy: Fatigue (FACT-F) version 4,
Functional Assessment of Cancer Therapy–General (FACT-G) version 4, and Beck Depression Inventory in 3 separate
times, namely, during the first week of radiotherapy, on the week of the intermediary phase, and during the last week of
radiotherapy. Individual 30- to 40-minute sessions of music therapy with the presence of a trained music therapist were
offered to participants. Results: In this study, 164 women were randomized and 116 (63 CG and 53 MTG) were included
in the analyses, with mean age of 52.90 years (CG) and 51.85 years (MTG). Participants in the MTG had an average of
10 music therapy sessions, totaling 509 sessions throughout the study. FACT-F results were significant regarding Trial
Outcome Index (P = .011), FACT-G (P = .005), and FACT-F (P = .001) for the MTG compared with the CG. Conclusions:
Individual music therapy sessions may be effective to reduce fatigue related to cancer and symptoms of depression, as well
as to improve quality of life for women with breast or gynecological cancer undergoing radiotherapy. Further well-designed
research studies are needed to adequately determine the effects of music therapy on fatigue.
Keywords
fatigue, breast cancer, gynecological cancer, radiotherapy, music therapy
Submitted August 28, 2015; revised December 4, 2017; accepted January 7, 2018

Alcântara-Silva et al 629
Fatigue treatment may include pharmacological and
nonpharmacological interventions. However, interventions
for CRF have been largely unsuccessful.6 The use of music
for therapeutic purposes is indicated in cancer treatment for
anxiety and depression, and for also for fatigue, based on
clinical trials.7,8 A professional music therapist adjusts the
experiences that music can offer to the patients’ needs in a
therapeutic relationship.9 A reduction of anxiety and depres-
sion in cancer patients who received music therapy was
observed in some studies.7,10 However, in the case of
fatigue, one recent review indicates that the trials on fatigue
offer only low-quality evidence, since they are poorly
designed.7 Therefore, this study aimed to verify the influ-
ence of music therapy on fatigue in patients with breast and
gynecological cancer undergoing radiotherapy.
Method
Study Design
This was a prospective, randomized study using music ther-
apy to alleviate fatigue and depressive symptoms.
Participants
Participants were female patients recruited from a cancer
treatment hospital located in the Midwest region of Brazil.
Inclusion criteria were the following: (1) diagnosis of breast
or gynecological cancer, (2) age between 20 and 80 years, (3)
scheduled to receive radiotherapy (teletherapy or brachyther-
apy) planned for 20 or more sessions, and (4) score of 70 or
more points in the Karnofsky Performance Scale Index.
Exclusion criteria were the following: (1) already undergoing
radiotherapy, (2) hemoglobin levels equal or less than 10 mg/
dL, (3) undergoing psychotherapeutic treatment during the
study period, (4) using antidepressants during the study
period, and (5) diagnosis of other types of cancer. Furthermore,
the patients who did not attend at least 75% of music therapy
sessions or had to interrupt radiotherapy for more than 10
days were discontinued.
Procedures
To carry out the randomization, 164 sealed envelopes con-
taining the names of the groups (control group [CG] and
music therapy group [MTG]) in identical proportions were
used (Figure 1). The participants were evaluated regarding
fatigue and quality of life at 3 different times: (1) at the
initial phase, during the first week of radiotherapy; (2) at the
intermediary phase, during the third or fourth weeks of
radiotherapy; and (3) at the final phase, during the last week
of radiotherapy. The symptoms of depression were assessed
at the initial and final phases of the study. The question-
naires were completed in the same period, independently of
the group. The CG received radiotherapy in the same hospi-
tal as the MTG.
Instruments
The sociodemographic variables were collected using a
questionnaire developed specifically for this study. To
assess fatigue, the Functional Assessment of Cancer
Therapy Fatigue (FACT-F) version 411 was applied in its
validated Portuguese version.12 The FACT-F scores range
from 0 (intense fatigue) to 52 (no fatigue).13 To measure the
intensity of depression, the Beck Depression Inventory was
employed in the validated Portuguese version.14,15 This is a
self-report composed of 21 items, with a 4-point scale for
each item ranging from 0 to 3, and the total score is the sum
of all items, ranging from 0 (no depression) to 63 (most
severe depression).14,15 At all scales, the participants
responded to how they felt over the past week.
Music Therapy
The music therapy sessions were conducted by a trained and
experienced music therapist (TRM Alcântara-Silva). The par-
ticipants in the MTG had individual 30- to 40-minute music
therapy sessions twice a week right before the radiotherapy ses-
sions, in the therapist’s office, in a cancer treatment hospital.
The strategy chosen was a therapeutic period listening to
music at 3 different times of each session, following the
protocol established for this research, that is, first listening,
second listening, and third listening. The selection of songs
for the first and third listening of each session was per-
formed by the music therapist based on her own repertoire
of the baroque, classical, and romantic periods.
For the first listening, 12 songs were chosen, which were
instrumental, with a slow tempo, a tone, and regular pulse.
These features generate a consonant melody, leading to
more pleasure during listening because of the activation of
the cortical region of the brain, related to pleasurable
responses to consonant musical stimuli.16 The music thera-
pist previously determined the sequence of the songs, so
that all the patients would listen to the same song in the first
music therapy session, in the second one, and so forth.
Since the total number of sessions ranged from 8 to 12, the
last song in the list was played in the last session of each
patient, regardless of the number of the session.
The selection of songs for the second listening was
patient-chosen by participants in the MTG, each of whom
gave the music therapist a list of her favorite songs. The
selection of the songs for the third listening followed the
same pattern already described for the first one, except that
the tempo was faster, and the last song in the period, also
chosen to be played in the last session of each patient,
regardless of the number of the sessions, was played by an
orchestra and singer.

630 Integrative Cancer Therapies 17(3)
The equipment used in the music therapy sessions
included the following: a fourth-generation iPod Nano
(Apple Inc, Cupertino, CA) and a Powerpack model SK-2
speaker. The music therapy sessions were conducted
according to a specific protocol developed for this study
and consisted of the following: (1) welcoming the patient
(5 minutes), a moment dedicated to receive the patient and
collect the study variables; (2) first listening (5 minutes);
(3) second listening (5 minutes); (4) talking (5 to 15 min-
utes), a period of time for the patients to the freely express
their feelings; (5) third listening (5 minutes); and (6)
ending the session (5 minutes), a moment dedicated for
brief personal reflection and patient leaving.
Statistical Analysis
Data were analyzed using dispersion and central tendency
measurements. Sociodemographic results and Beck
Depression Inventory variables were analyzed using the χ2
test with analysis of relative risk. For FACT-F variables, the
Wilcoxon test and the Kruskal-Wallis test were applied to
assess the intragroup and intergroup statistical differences
Figure 1. Diagram of randomization.

Alcântara-Silva et al 631
between the CG and the MTG, respectively. The results
were considered statistically significant at the 95% confi-
dence interval when P < .05.
Ethics Statement
This study was approved by the Research Ethics Committee
of the Associação de Combate ao Câncer em Goiás (CEP/
ACCG, No. 054/09) and it was conducted in accordance
with the ruling principles of the Helsinki Convention. The
participants were volunteers, and they signed a free and
informed consent statement before their inclusion in the
study, having received information about the study, its aims,
and its probable side effects and future advantages.
Results
The sociodemographic characteristics of the 116 partici-
pants are presented in Table 1. The mean age of the partici-
pants was 52.90 (±10.26) years for the CG and 51.85
(±10.60) years for the MTG. The clinical characteristics of
the participants are shown in Table 2. The main reasons for
exclusion of the patients were the use of antidepressants
during the study (n = 3), the hemoglobin level below 10 mg/
dL (n = 2), and delayed onset of radiotherapy (n = 2). The
main reasons for discontinuation were interruption of radio-
therapy for more than 10 days (n = 7), number of music
therapy sessions less than 75% of the planned sessions (n =
5), and temporal impossibility to participate in the sessions
(n = 3) or to respond to the questionnaire (n = 6), in addition
to 5 patients who left the study without justification.
Participants in the MTG (n = 53) had an average of 10
music therapy sessions, totaling 509 individual appoint-
ments during the study. For these patients, all the FACT-F
variables were statistically significant (P < .05): Trial
Outcome Index (TOI), Functional Assessment of Cancer
Therapy: General (FACT-G), and FACT-F (Table 3 and
Figures 2-4).
Comparing the variables of the 3 phases of assessment
within the same group (Wilcoxon test), the data obtained for
Table 1. Sociodemographic Characteristics of the Participants According to the Group of Inclusion in the Study.
Variables
CG MTG
P95% CIn % n %
Race
Caucasian 20 34.5 22 44.9 1.00
African 6 10.3 3 6.1 .25 0.45 (0.10-2.06)
Asian 6 10.3 2 4.1 .15 0.30 (0.05-1.67)
Indian 1 1.7 0 0.0 .30 0.47 (0.34-0.65)
Mulatto 25 43.1 22 44.9 .60 0.80 (0.34-1.84)
Marital status
Married 38 64.4 36 69.2 1.00
Single 10 16.9 6 11.5 .41 0.63 (0.21-1.92)
Widow 5 8.5 5 9.6 .93 1.056 (0.28-3.95)
Separated 2 3.4 1 1.9 .60 0.52 (0.04-6.07)
Divorced 4 6.8 4 7.7 .94 1.05 (0.24-4.54)
Education level
Illiterate 5 9.8 5 10.9 1.00
Elementary school level 1 16 31.4 13 28.3 .77 0.81 (0.19-3.42)
Elementary school level 2 14 27.5 9 19.6 .56 0.64 (0.14-2.87)
High school 10 19.6 11 23.9 .90 1.10 (0.24-4.96)
College 6 11.8 8 17.4 .72 1.33 (0.26-6.80)
Physical activity
Sedentary 42 82.4 39 88.6 .33 1.00
Active 9 17.6 5 11.4 .44 1.34 (0.64-2.82)
Tobacco consumption
No 34 65.4 36 73.5 1.00
Yes 4 7.7 5 10.2 .81 1.18 (0.29-4.76)
Ex-smoker 14 26.9 8 16.3 .21 0.54 (0.20-1.45)
Alcohol consumption
No 52 100.0 48 98.0 1.00
Yes 0 0.0 1 2.0 .30 —
Abbreviations: CG, control group; MTG, music therapy group; CI, confidence interval.

632 Integrative Cancer Therapies 17(3)
the CG with FACT-F did not present significant response in
the domains TOI, FACT-G, and FACT-F, whereas the data
obtained for the MTG showed significant improvement in
the same domains (P < .01). Patients in the MTG showed
improvement in symptoms of depression, which were
reduced to the minimum level (P = .005), and a 74% reduc-
tion in risk of depression (relative risk = 0.26%; 95% CI =
0.10-0.70).
Table 2. Clinical Characteristics of the Participants and Type of Treatment According to the Group of Inclusion in the Study.
Variables
CG MTG
P95% CIn % n %
Types of cancer
Breast 47 73.4 43 81.1 1.00
Gynecological 17 26.6 10 18.9 .32 0.64 (0.26-1.55)
Staging
In situ 4 6.5 0 0.0 1.00
I 19 30.6 10 18.9 .16 1.52 (1.17-1.98)
II 16 25.8 20 37.7 .03 2.25 (1.56-3.24)
III 19 30.6 16 30.2 .08 1.84 (1.36-2.50)
IV 4 6.5 6 11.3 .04 2.50 (1.17-5.34)
Surgery
No 9 14.3 9 17 1.00
Yes 54 85.7 44 83 .69 0.81 (0.30-2.23)
Chemotherapy
No 22 34.9 14 26.4 1.00
Yes 41 65.1 39 73.6 .32 1.50 (0.67-3.33)
Radiotherapy (no. of sessions)
21-25 20 31.7 15 28.3 1.00
26-30 43 68.3 37 69.8 .73 1.14 (0.51-2.55)
Abbreviations: CG, control group; MTG, music therapy group; CI, confidence interval.
Table 3. Assessment of Fatigue in the 3 Domains of the FACT-F During Radiotherapy According to the Group of Inclusion in the
Study.
Variables Timing of Assessment Group n Mean Values P
TOI Initial CG 65 61.15 .561
MTG 53 57.47
Intermediary CG 54 49.64 .617
MTG 47 52.56
Final CG 64 51.74 .011
MTG 53 67.76
FACT-G Initial CG 65 58.20 .647
MTG 53 61.09
Intermediary CG 54 47.23 .166
MTG 47 55.33
Final CG 64 50.93 .005
MTG 53 68.75
FACT-F Initial CG 65 59.28 .940
MTG 53 59.76
Intermediary CG 54 48.34 .328
MTG 47 54.05
Final CG 64 51.59 .009
MTG 53 67.95
Abbreviations: FACT-F, Functional Assessment of Cancer Therapy: Fatigue; TOI, Trial Outcome Index; CG, control group; MTG, music therapy group;
FACT-G, Functional Assessment of Cancer Therapy: General.

Alcântara-Silva et al 633
Discussion
The present study indicated a possible association between
fatigue and quality of life, since the participants in the MTG
experienced improvements in both aspects after the music
therapy sessions. This finding is corroborated by a recent
meta-analysis that pointed to a decrease in fatigue and an
increase in quality of life of cancer patients after music
interventions.7
In a comparative analysis of the CG and MTG, taking
into consideration the 3 phases of assessment, the fatigue
profile was at similar levels at the beginning of the study for
patients in both groups and improved in the final phase of
treatment in both groups. However, the participants in the
MTG showed statistically significant improvement com-
pared with the CG patients under the same conditions
(Figures 2-4). Therefore, it is possible to infer that the par-
ticipants in the MTG experienced improvement in fatigue
symptoms because of music therapy.
In this study, music therapy significantly reduced the
symptoms of depression, and hence it can be considered an
adjuvant therapy for the treatment of cancer patients
(Table 4). This outcome is in accordance with other results
described in the literature.17-19 The emotional support pro-
vided by music therapy may justify the statistically signifi-
cant improvement of fatigue symptoms experienced by the
participants in the MTG. From the neurophysiological point
of view, the music-evoked emotions can modulate activity
in virtually all limbic and paralimbic brain structures. These
structures are crucially involved in the initiation, genera-
tion, detection, maintenance, regulation, and termination of
emotions, which are constantly present in the life of
the individual. Therefore, at least some music-evoked emo-
tions involve the very core of adaptive neuro-affective
mechanisms.20,21 Thus, music therapy can bring several
benefits to cancer patients, helping them to find ways to
deal with stress, fear, and loneliness.22,23
Nonetheless, the benefits of music therapy in the man-
agement of fatigue remain uncertain and some authors
reported no positive effects in improving physical and
psychological aspects of cancer patients.7,24 This differ-
ence may be explained by differences in methods of music
therapy intervention, or even in the techniques applied and
Figure 2. Assessment of the domain Trial Outcome Index
during radiotherapy, according to the group of inclusion in the
study, using the Functional Assessment of Cancer Therapy:
Fatigue.
Abbreviations: CG, control group; MTG, music therapy group.
Figure 4. Assessment of the variable fatigue during
radiotherapy, according to the group of inclusion in the study,
using the Functional Assessment of Cancer Therapy: Fatigue.
Abbreviations: CG, control group; MTG, music therapy group.
Figure 3. Assessment of the variable quality of life during
radiotherapy, according to the group of inclusion in the study,
using the Functional Assessment of Cancer Therapy: Fatigue.
Abbreviations: CG, control group; MTG, music therapy group.
Table 4. Comparative Analysis of Categories (χ2 test) During
Radiotherapy According to the BDI.
Variables
CG MTG
PRR (95% CI)n % n %
BDI—Initial phase
Minimum 36 65 34 64 .88 1.00
Mild to intense 9 16 10 19 0.97 (0.65-1.44)
BDI—Final phase
Minimum 35 64 46 87 .005 1.00
Mild to intense 11 20 5 9 0.26 (0.10-0.70)
Abbreviations: BDI, Beck Depression Inventory; CG, control group;
MTG, music therapy group; RR, relative risk; CI, confidence interval.

634 Integrative Cancer Therapies 17(3)
the number of sessions offered.25 Therefore, our random-
ized trial is a contribution to this literature because it stud-
ies music therapy in the radiotherapy setting for Brazilian
patients.
In this study, most songs chosen by the patients
approached themes similar to the feelings they were experi-
encing during radiotherapy, such as loss, loneliness, and
sorrow. Familiar songs play an important role in music ther-
apy, because they allow latent contents to emerge, and they
also help the patients to become aware of their problems
and look for more adaptive coping strategies, leading to a
better understanding of the treatment, and alleviation of the
symptoms for most individuals.20
The biological facts underlying the results found in this
study may be connected to the relationship of music with
deep brain structures involved in the processing of emo-
tions.17,18 Therefore, music plays a major role in self-regula-
tion of emotional contexts.26 Music is also involved in the
regulation and genetic expression of dopamine,27 as well as
in the alterations in the levels of serotonin, cortisol, and
oxytocin.28 Hence, it is possible to affirm that the positive
response obtained with the action of music in the therapeu-
tic context, applied by a qualified music therapist, is based
on biopsychosocial grounds.
Fatigue is still underdiagnosed, although it is one of the
most important symptoms affecting cancer patients.
Because of the indisposition it causes, in many cases fatigue
may limit or even prevent the continuity of radiotherapy.
Therefore, fatigue treatment should be given a high priority
in a multidisciplinary approach of pharmacotherapeutic and
nonpharmacotherapeutic interventions. However, it is
highly important to diagnose it during the initial appoint-
ments, so that it can be properly treated, inasmuch as fatigue
level before the treatment is a significant predictor of this
condition during and after radiotherapy.29 Moreover, it is
necessary to enlighten patients and family members about
fatigue symptoms and treatment. Interdisciplinary teams
are valuable to adequate patients’ individual needs.
In the present study, the discontinuation rate was higher
than expected. Some of the losses to follow-up may be
attributed to the schedule of the appointments, radiotherapy
and chemotherapy side effects, and family situations.
Among the limitations of the study, the difficulty of blind-
ing the participants (open-label study) and the small individual
variations in the music therapy sessions are worth mentioning.
Therefore, the interpretation of the study results should be cau-
tious, because of the nonblinded nature of the study.
Nonetheless, these features are inherent to studies involving
musical interventions. Another limitation was the absence of a
time-and-attention control group, considering the possibility of
a placebo effect because of the time spent with a therapist and
the personal attention received from the therapist.
Finally, the following suggestions are aimed at contrib-
uting to future studies: (1) create programs to inform
patients and family members about fatigue and its repercus-
sion in breast or gynecological cancer patients’ quality of
life and treatment; (2) implement educational programs to
enlighten patients and family members about fatigue symp-
toms; (3) establish a protocol for the evaluation of CRF, as
well as for screening and treating it before and during radio-
therapy; and (4) add a music therapist to the multiprofes-
sional team in charge of the treatment of fatigue and other
symptoms experienced by patients during radiotherapy.
Conclusion
Music therapy can be applied as an integrative treatment
during radiation therapy and has the potential to affect
fatigue. In this study, statistically relevant responses were
found regarding fatigue, quality of life, and symptoms of
depression. Continuous assessment of results, in the begin-
ning, during, and after radiotherapy is also relevant.
Moreover, assessment during radiotherapy allows profes-
sionals to rethink and adjust the procedures aimed to achieve
effective responses to treatment, as well as minimize the
number of patients who abandon it. Further well-designed
research studies are needed to adequately determine the
effects of music therapy on fatigue.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Tereza Raquel de Melo Alcântara-Silva https://orcid.org/0000-
0002-9363-5747
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