Abstract
Objective:
The aim of this study was to retrospectively analyze the effect of music therapy on patients with end-stage cancer in hospice care.
Methods:
This retrospective cohort study included 195 patients with end-stage cancer from January 2021 to December 2023. The conventional group comprised patients who received routine hospice care, whereas the combination group comprised those who received routine hospice care and music therapy. The immune indicators, anxiety and depression scores, quality of life scores, and sleep quality scores of both groups were compared before and after management.
Results:
Before management, no significant differences were observed in the immune indicators, anxiety and depression scores, quality of life scores, and sleep quality scores between both groups (P > 0.05). However, after management, the immune indicators lymphocytes CD3+ and CD4+ were significantly higher in the combination group than in the conventional group (P < 0.05); in contrast, anxiety and depression and the Pittsburgh Sleep Quality Index scores were lower in the combination group than in the conventional group (P < 0.05). Lastly, the World Health Organization Quality of Life Brief Version scores were significantly higher in all domains in the combination group than in those in the conventional group; furthermore, the degree of decline in the physical, psychological, and social relationship domain scores was smaller in the combination group than in the conventional group (P < 0.05).
Conclusion:
For patients with end-stage cancer, music therapy can improve their immune status, quality of life, and sleep and ameliorate their anxiety and depression.
Keywords: Music therapy, End-stage, Cancer, Hospice care
INTRODUCTION
Cancer is a leading reason for mortality worldwide.[1] Patients with end-stage cancer not only suffer from physical pain but also endure psychological trauma. Hospice care is routinely administered to patients with end-stage cancer. This type of care is based on the theory of palliative care and aims to provide active holistic care to patients of different ages to improve the quality of life of patients as well as nursing staff. In hospice care, patient-centered and symptom-focused care is provided to patients who are terminally ill,[2] benefiting children with cancers and their families.[3] However, because it is a traditional medical management method, entirely covering the clinical needs of patients with end-stage cancer remains challenging.
Music can affect human behavior and can be employed as a complementary therapy in healthcare.[4] It is widely applied as a nonpharmacological intervention in clinical settings.[5] Patients with end-stage cancer frequently suffer from physical pain, psychological anxiety, depression, and other challenges during treatment. Music exerts a multimodal activation effect on the brain,[6] decreasing anxiety, avoiding the body’s reaction to various stress conditions through psychological adjustment, and improving adverse reactions.[7] Furthermore, music therapy is not only affordable but also easy to perform and has low risk. In addition, it can help patients relax physically and mentally, promote communication between patients and family members, strengthen emotional exchange, and provide a warmer and more humane atmosphere for hospice care for families. Warth et al.[8] have reported that music therapy is an effective and low-dropout treatment strategy that promotes relaxation and well-being in terminally ill patients receiving palliative care. However, sufficient research supporting the specific effects of music therapy in home hospice care for patients with end-stage cancer is lacking.
Therefore, in this retrospective study, we systematically elucidated the effects of music therapy in patients with end-stage cancer receiving family hospice care. Furthermore, we explored the potential role of music therapy in relieving the physical and psychological symptoms of patients to provide a more scientific and practical reference for the future application of music therapy in clinical settings.
MATERIALS AND METHODS
Research Methods
In this retrospective cohort study, 204 patients with end-stage cancer who were admitted to Datuan Community Health Service Center in Pudong New District of Shanghai from January 2021 to December 2023 were selected as participants. Based on whether they received music therapy, the participants were divided into two groups: conventional and combination groups.
Inclusion and Exclusion Criteria
The inclusion criteria were as follows: (1) all patients with end-stage malignant tumors confirmed via clinical, imaging, and pathological examination; (2) age <80 years; (3) patients with a survival time of >3 months; and (4) patients with complete clinical data.
The exclusion criteria were as follows: (1) patients with swallowing difficulties, risk of choking, and intestinal obstruction; (2) those with hematopoietic or immune system diseases; (3) those with severe infection; and (4) those with mental illness.
Ethical Approval
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Shanghai Pudong New Area Datuan Community Health Service center (approval number: 20200904).
Management Methods
Conventional Group
Both outpatient and follow-up management were conducted. During the patients’ return visit to the outpatient department and regular family follow-ups, relevant therapies were administered to evaluate their negative emotions, disease coping mechanisms, etc, as well as their psychological or emotional changes. Thereafter, corresponding psychological management was administered to help patients maintain peace of mind as far as possible. The family members should be around the patients 24 hours in rotation. Furthermore, the family members were actively encouraged to grasp the patient’s true thoughts as far as possible to meet their end-of-life requirements. In addition, pain education and medication guidance were provided to patients and their families.
The patients in the conventional group received family hospice care, which included symptomatic treatment such as analgesia, constipation relief, and oxygen inhalation. Furthermore, the family received nutritional support daily to meet the patient’s needs. Before and during nutritional supplementation, 200 to 300 mg of vitamin B1 was supplemented daily along with balanced mixtures of micronutrients. The following electrolytes were monitored and replaced via oral, enteral, or parenteral routes as needed: potassium (requirement of approximately 24 mmol/kg/day), phosphate (requirement of approximately 0.3–0.6 mmol/kg/day), and magnesium (intravenous supply of approximately 0.2 mmol/kg/day and oral supply requirement of approximately 0.4 mmol/kg/day).[9]
The number and frequency of follow-up visits was once every 5 days via phone or face-to-face visits. The management period was 1 month, with observation of clinical effects.
Combination Group
Based on the conventional group, the combination group received music therapy. First, patients were communicated with and their basic situation and personal music preferences were combined. Approximately 7 to 10 suitable songs were selected from the music library. Music primarily comprising light music, folk songs, and ballads was played. Most pieces with lively, melodious, and relaxing tunes were selected. The patient was positioned in a comfortable supine position while listening to music. The music decibel level was 30 to 40 decibels, and when combined with the patient’s best feeling, the maximum music decibel was 50 decibels. Simultaneously, the temperature and humidity of the treatment room were reasonably adjusted, and attention was paid to the cleanliness and hygiene of the floor. The frequency of music therapy was 1 time/day, with a duration of 30 to 60 minutes.
The number and frequency of follow-up visits were every 5 days via telephone or face-to-face visits. The management time was 1 month, with observation of clinical efficacy.
Observation Indicators
Before and after management, the general information and related indicators, including immunity status, mental health, and quality of life, of patients were collected.
Immune indicators: Fasting venous blood samples (3 mL) were collected from both patient groups before early morning management and at the last follow-up. The blood samples were centrifuged to obtain serum. The T lymphocyte subsets (CD3+, CD4+, CD8+, and CD4+/CD8+) and natural killer (NK) cells before and after patient management were detected using the Cell Signaling Technology (CST) human T lymphocyte subsets/NK cell detection kit (batch number: 40404ES50, Yisheng Biotechnology Co, Ltd, Shanghai, China).
Mental health indicators: The self-rating anxiety scale[10] was used to assess the subjective feelings of individuals with anxiety symptoms to measure anxiety severity and treatment changes. This scale comprises 20 items, with each item having 1 to 4 points and a total score of 80 points. The Cronbach’s α coefficient and content validity of the scale are 0.842 and 0.836, respectively. In addition, the Self-Rating Depression Scale,[11] a scale recommended for use in psychopharmacological studies by the US Department of Education, Health and Welfare, was used. It comprises 20 items, with each item having 1 to 4 points and a total score of 80 points. The Cronbach’s α coefficient and content validity of this scare are 0.844 and 0.836, respectively.
Quality of life score: Before and after management, the quality of life of both patient groups was assessed using the World Health Organization Quality of Life Brief Version (WHOQOL-BREF).[12] WHOQOL-BREF combines four domains: physical, psychological, social relationship, and environmental domains. The scoring standards for each dimension are as follows: 7 to 35, 11 to 55, 3 to 15, and 3 to 15 points, respectively. A high score suggests a high quality of life. The Cronbach’s α coefficient and content validity of the scale are 0.901 and 0.798, respectively.
Sleep quality score: Before and after management, the Pittsburgh Sleep Quality Index (PSQI) was utilized to evaluate the sleep quality of the cohort.[13] This scale has a total score of 0 to 21 points. The higher the score, the worse the sleep quality. The Cronbach’s α coefficient and content validity of the scale are 0.850 and 0.813, respectively.
Statistical Analysis
Data analysis was performed using SPSS 25.0 statistical software (International Business Machines Corporation, Armonk, New York, USA). The statistical data were represented using [n (%)] and the χ2 test was performed. The Shapiro–Wilk method was employed to test the normal distribution of continuous variables. The data following normal distribution were represented using (x̅ ± s) and a t-test was performed. The data that did not follow normal distribution were expressed using [M (P25, P75)] and the Mann–Whitney U test was performed. A P-value of <0.05 was considered statistically significant.
RESULTS
Comparison of the General Characteristics of Both Patient Groups
In total, 204 patients were included in this study; 100 patients were included in the combination group and 104 in the conventional group. Based on the inclusion and exclusion criteria, we excluded six patients with severe swallowing difficulties and intestinal obstruction and three patients with severe infection. Finally, 195 patients were included, with 95 in the combination group and 100 in the conventional group.
Table 1 compares the general characteristics, such as age, illness duration, surgical history, and chemotherapy history, between both patient groups; no statistically significant difference (P > 0.05) was observed.
Table 1.
Comparison of the General Characteristics between Both Patient Groups (n, %).
| Combination Group (n = 95) | Conventional Group (n = 100) | χ2/z | P | |
|---|---|---|---|---|
| Sex | 0.300 | 0.584 | ||
| Man | 55 (57.89) | 54 (54.00) | ||
| Woman | 40 (42.11) | 46 (46.00) | ||
| Age [years, M (P25, P75)] | 67.00(63.00, 73.00) | 68.50(63.00, 73.50) | −0.705 | 0.481 |
| Education | 1.215 | 0.270 | ||
| Junior high school or below | 74 (77.89) | 71 (71.00) | ||
| High school or above | 21 (22.11) | 29 (29.00) | ||
| Medical self-payment method | 0.125 | 0.723 | ||
| Employee medical insurance | 62 (65.26) | 67 (67.00) | ||
| Resident medical insurance | 29 (30.53) | 28 (28.00) | ||
| Self-finance | 4 (4.21) | 5 (5.00) | ||
| Illness duration [years, M (P25, P75)] | 3.10(2.20, 4.00) | 2.70(1.95, 3.70) | −1.479 | 0.139 |
| Cancer type | 1.091 | 0.779 | ||
| Lung cancer | 30 (31.58) | 35 (35.00) | ||
| Gastrointestinal neoplasms | 27 (28.42) | 24 (24.00) | ||
| Prostate cancer | 17 (17.89) | 15 (15.00) | ||
| Breast cancer | 21 (22.11) | 26 (26.00) | ||
| Surgical history | 90 (94.74) | 92 (92.00) | 0.586 | 0.444 |
| Radiotherapy and chemotherapy history | 88 (92.63) | 90 (90.00) | 0.424 | 0.515 |
| Self-care life | 10 (10.83) | 9 (9.00) | 0.129 | 0.719 |
Comparison of the Immune Indicators between Both Patient Groups Before and After Management
Before management, no statistically significant differences were observed in the immune indicators lymphocytes CD3+ and CD4+ between both patient groups (P > 0.05). However, after management, these indicators were significantly higher in the combination group than in the conventional group, with statistically significant differences between both groups (P < 0.05) [Table 2].
Table 2.
Comparison of the Immune Indicators between Both Patient Groups Before and After Management [M (P25, P75)].
| Indicator | Combination Group (n = 95) | Conventional Group (n = 100) | z | P | |
|---|---|---|---|---|---|
| CD3+(%) | Before management | 45.60 (38.80, 52.05) | 43.55 (37.40, 51.20) | −0.876 | 0.381 |
| After management | 52.50 (45.55, 58.75) | 48.20 (44.50, 51.85) | −4.447 | <0.001 | |
| CD4+(%) | Before management | 33.90 (30.00, 38.65) | 34.90 (28.90, 38.85) | −0.343 | 0.732 |
| After management | 36.10 (34.60, 37.80) | 33.70 (31.75, 36.00) | −5.897 | <0.001 | |
| CD8+(%) | Before management | 27.20 (25.00, 30.15) | 26.90 (25.00, 28.90) | −1.002 | 0.317 |
| After management | 29.10 (27.55, 30.45) | 27.65 (26.50, 29.15) | −4.055 | <0.001 | |
| CD4+/CD8+(%) | Before management | 1.24 (1.09, 1.40) | 1.23 (1.06, 1.46) | −0.278 | 0.781 |
| After management | 1.26 (1.17, 1.32) | 1.21 (1.14, 1.29) | −2.436 | 0.015 | |
| NK(%) | Before management | 14.80 (12.75, 17.25) | 15.75 (12.80, 17.20) | −0.980 | 0.327 |
| After management | 16.60 (14.80, 17.55) | 14.80 (13.75, 16.05) | −4.706 | <0.001 |
NK = natural killer
Comparison of Anxiety and Depression Scores between Both Patient Groups Before and After Management
Before management, no significant differences were observed in the anxiety and depression scores between both groups (P > 0.05). However, after management, the anxiety and depression scores were lower in the combination group than in the conventional group, with statistical differences between both groups (P < 0.05) [Table 3].
Table 3.
Comparison of the Anxiety and Depression Scores between Both Patient Groups Before and After Management [M (P25, P75), Score].
| Group | Anxiety Score | Depression Scores | ||
|---|---|---|---|---|
|
|
|
|||
| Before Management | After Management | Before Management | After Management | |
| Combination group (n = 95) | 60.00 (56.00, 65.00) | 57.00 (54.00, 61.50) | 59.00 (56.00, 65.00) | 56.00 (51.50, 59.00) |
| Conventional group (n = 100) | 62.00 (56.00, 67.00) | 61.00 (55.00, 65.00) | 59.00 (55.00, 63.50) | 58.00 (54.00, 61.00) |
| z | −1.393 | −3.796 | −0.654 | −2.740 |
| P | 0.164 | <0.001 | 0.513 | 0.006 |
Comparison of the Quality of Life Scores between Both Patient Groups Before and After Management.
Before management, no statistically significant differences were observed in the WHOQOL-BREF scores of each domain between both groups (P > 0.05). However, after management, the WHOQOL-BREF scores of each domain were significantly higher in the combination group compared to the conventional group (P < 0.05). Furthermore, the degree of decline in the scores of the physical, psychological, and social relationship domains was smaller in the combination group compared to the conventional group, with statistically significant differences (P < 0.05) [Table 4].
Table 4.
Comparison of the Quality of Life Scores between Both Patient Groups Before and After Management [M (P25, P75), (x̅ ± s), Score].
| Project | Time | Combination Group (n = 95) | Conventional Group (n = 100) | z/t | P |
|---|---|---|---|---|---|
| Physical | Before management | 17.00 (15.00, 21.00) | 17.50 (15.00, 20.00) | −0.534 | 0.593 |
| After management | 15.00 (13.00, 17.00) | 13.00 (12.00, 15.50) | −5.042 | <0.001 | |
| Difference score 1 | 2.20 ± 0.46 | 3.86 ± 0.39 | −2.847 | 0.007 | |
| Psychological | Before management | 20.00 (18.00, 22.00) | 21.00 (18.00, 23.00) | −1.430 | 0.153 |
| After management | 16.00 (14.00, 18.00) | 15.00 (13.00, 16.00) | −5.039 | <0.001 | |
| Difference score 2 | 3.00 (2.00, 6.00) | 5.00 (4.00, 8.00) | −4.334 | <0.001 | |
| Social relationship | Before management | 11.00 (9.50, 11.50) | 10.00 (9.00, 11.00) | −1.665 | 0.096 |
| After management | 8.00 (6.50, 9.00) | 7.00 (5.00, 9.00) | −3.633 | <0.001 | |
| Difference score 3 | 3.00 (1.00, 4.00) | 4.00 (2.00, 5.00) | −2.622 | 0.009 | |
| Environmental | Before management | 11.00 (10.00, 12.00) | 11.00 (9.00, 12.00) | −1.751 | 0.080 |
| After management | 9.00 (8.00, 10.00) | 8.00 (7.00, 10.00) | −2.878 | 0.004 | |
| Difference score 4 | 2.00 (1.00, 3.50) | 3.00 (0.00, 4.00) | −0.861 | 0.389 |
Difference score 1 = before treatment (physical domain) − after treatment (physical domain); difference score 2 = before treatment (psychological domain) − after treatment (psychological domain); difference score 3 = before treatment (social relationship domain) − after treatment (social relationship domain); and difference score 4 = before treatment (environmental domain) − after treatment (environmental domain).
Comparison of the Sleep Quality Scores between Both Patient Groups Before and After Management
Before management, there was no statistically significant difference in PSQI scores between the two groups (P > 0.05). However, after management, the PSQI scores of the combination group were lower than those of the conventional group, with statistically significant differences between the groups (P < 0.05) [Table 5].
Table 5.
Comparison of the Sleep Quality Scores between Both Patient Groups Before and After Management [M (P25, P75), Score].
| Project | Time | Combination Group (n = 95) | Conventional Group (n = 100) | z | P |
|---|---|---|---|---|---|
| Total score | Before management | 16.00 (13.00, 18.00) | 15.50 (12.50, 19.00) | −0.335 | 0.738 |
| After management | 13.00 (11.00, 15.00) | 14.00 (12.00, 17.00) | −2.384 | 0.017 |
DISCUSSION
Infiltration, metastasis, and damage to nearby organs and tissues are commonly observed in patients with end-stage cancer, accompanied by varying degrees of pain and negative emotions and significant effects on the quality of life. Most patients with end-stage cancer do not require hospitalization and frequently receive home hospice care. Patients with advanced cancer who experience mental distress require psychiatric care[14]; however, no uniform conclusion is available on the specific measures of home hospice care for such patients.
Over the past few decades, the application of music therapy has increased in various medical fields. Recent neuroscientific literature suggests that music significantly converges pain matrices and pleasure neuron networks.[15] In the present study, we observed no differences in the anxiety and depression scores between both groups before management (P > 0.05); however, after management, the anxiety and depression scores were lower in the combination group than in the conventional group (P < 0.05). This indicates that music therapy can improve the depression and anxiety symptoms of patients. This is because music is a type of special information that is similar yet different from language and other sounds and can exert good physiological effects on various systems in the human body. Music therapy may affect the dynamic functional connectivity of striatal-default mode network circuits.[16] Furthermore, it is based on the peripheral–central nervous system of the hypothalamic–brainstem–autonomic nervous system axis.[17] Neurophysiologically, music-induced emotions can alter the activities in nearly all limbic and paralimbic regions,[18] making it a low-touch, low-risk, and cost-effective approach.[19]
The immune system of terminally ill patients is often severely damaged after long-term treatment. Ghetti[20] has reported that negative emotions can lead to immune dysregulation and poor health. Musical sound waves act on the brain. Sparing et al.[21] have reported that the excitability of the right motor cortex increases during public singing and humming. In the present study, we observed no differences in immune indicators such as lymphocytes CD3+ and CD4+ between both groups before management (P > 0.05); however, after management, these indicators were significantly higher in the combination group than in the conventional group (P < 0.05). This indicates that music therapy can effectively improve the immune status of patients with end-stage cancer. Music therapy affects the autonomic nervous system, and musical rhythms exert strong actionable and positive emotional effects in music therapy, directly evoking various emotional and dynamic neurological changes in the brain.[22] This improves immune dysregulation in patients.
In addition, patients with end-stage cancer suffer from physical and mental discomfort caused by the disease, with a decrease in their quality of life. Before management, no significant differences were observed in the WHOQOL-BREF scores of each domain between both groups (P > 0.05); however, after management, the WHOQOL-BREF scores of each domain were significantly higher in the combination group than in the conventional group (P < 0.05). Furthermore, the degree of decline in the physical, psychological, and social relationship domain scores was smaller in the combination group than in the conventional group (P <0.05); this indicates that music therapy can improve the quality of life of patients with end-stage cancer. This is because music can directly decrease anxiety levels, enhance patients’ sense of well-being and control,[23] promote human homeostasis, and improve their quality of life. Our study findings suggest no significant differences in the PSQI scores of both groups before management; however, after management, the PSQI scores of the combination group were lower than those of the conventional group (P <0.05). This indicates that music therapy can improve the sleep quality of patients with end-stage cancer. This is because music therapy can play a soothing role in the nervous system, regulate hormone and cortisol secretion,[24] release the pressure and pain of patients with cancer,[25] and allow them to fall asleep faster and alleviate their cancer-related fatigue.
Our study still has some limitations. Firstly, the patients were from a single institution, with no further expansion of the sample size. Second, information on additional indicators could have been collected. In the future, other research methods, such as prospective studies, should be employed to determine the effect of music therapy on patients with end-stage cancer.
CONCLUSIONS
Music therapy can improve the immune status and sleep quality of patients with end-stage cancer, decrease their negative emotions and improve their quality of life. However, this study still has shortcomings, including a single-center retrospective study and the absence of long-term follow-up results, which should be further improved in the future.
Financial support and sponsorship
Nil.
Conflict of interest
None.
Declaration of Interests
The authors declare no conflict of interest.
Funding Statement
Funding: This study was funded by Shanghai Pudong New Area Health Commission Excellent Young Medical Talent Training Plan, Grant No. PWRq2020-70.
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