Psycho-Oncology

Psycho-Oncology 26: 377–384 (2017)

Published online 5 May 2016 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.4142

The effects of music therapy in patients with high-dose

chemotherapy and stem cell support: a randomized pilot study
Gert Tuinmann1*,†, Pia Preissler2,†, Hauke Böhmer2, Anna Suling3 and Carsten Bokemeyer2
1
Medical Department, Division of Psychosomatic Medicine, Charité – Campus Benjamin Franklin, Berlin, Germany
2
Department of Internal Medicine II, Hubertus-Wald Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
3
Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
*Correspondence to: Abstract
Medical Department, Division of
Psychosomatic Medicine, Charité Objective: Patients with high dose chemotherapy (HDC) with autologous stem cell transplantation
– Campus Benjamin Franklin, (ASCT) are highly distressed. Psycho-oncological support might be beneficial but is not routinely
12200 Berlin, Germany. E-mail: provided. Our aim was to investigate whether music therapy (MT) in addition to standard supportive
gert.tuinmann@charite.de treatment had any effect on quality of life, depression, anxiety, side effects of therapy, medication, and
†
equally contributed first authors immunological changes during and within three months after HDC plus ASCT.
Parts of this manuscript were Methods: Patients (n = 66) with HDC plus ASCT were randomly assigned to either MT (Intervention
presented from G. Tuinmann at Group = IG) or standard supportive treatment (Control Group = CG). Quality of life was measured by
the DKPM in Heidelberg 2013 EORTC QLQ-C30. Depression and anxiety were measured by the HADS-D before transplantation,
(poster) and Berlin (oral during and after the inpatient stay. In addition, adverse events (AE), medication, and immunological
presentation) 2014 and from P.
parameters were observed.
Preissler at the PSO congress
Results: There was no improvement of global quality of life for patients receiving additional MT,
2012 in Hamburg (poster).
but their perception of pain significantly changed (p = 0.027). Patients were neither depressed nor
anxious on admission, therefore no improvements were found. IG patients had less 3–4° toxicities
(e.g., mucositis). Aprepitant for antiemetic therapy was administered significantly more often in the
CG (p = 0.040). The IgA decline and T4 count was less in IG, T8, and NK count decreased most in
IG. These findings failed significance.
Conclusions: MT may improve pain perception in patients receiving HDC plus ASCT. Additionally
Received: 21 August 2015 positive effects on toxicities, use of antiemetic medication, and immunological changes were observed.
Revised: 23 March 2016 As some of these findings failed significance, studies with larger sample sizes are needed.
Accepted: 25 March 2016 Copyright © 2016 John Wiley & Sons, Ltd.

Background T4/T8 ratio) could result, especially in depressive

Most patients with hematological malignancies receiving
high dose chemotherapy (HDC) experience immense
psychological distress. This especially applies to patients
who have been admitted for an autologous stem cell
transplantation (ASCT) after HDC [1]. The complexity
of the somatic and psychological pressure can exceed
patients’ coping strategies leading to an impaired
quality of life and mood disturbances, anxiety, and
depression.
The recovery after stem cell transplantation may take
several months to years [2]. Even then, these patients are
impaired on different psychosocial levels compared with
healthy controls [3]. Fatigue is commonly found in
patients even years after ASCT [4,5]. Also, global quality
of life seems to be impaired and physical functioning
deteriorated in some patients [6].
Prior to, during or following ASCT there is a risk of
depression, anxiety, and distress [7,8]. Moreover, as a
transplantation may be a major stressor, immunological
changes (Lymphocytes, immunoglobulins, NK-cells,
patients [9,10]. Sherman and colleagues [11] reported
psychological disturbances in up to 40% in patients with
multiple myeloma (MM) at the time of stem cell
collection. The depression rate after HDC plus ASCT
is up to 17.5% [12,13]. Mortality after ASCT is increased,
especially in patients with major depression. Some risk
factors for psychiatric disorders in hematological cancer
with ASCT have been found: younger age, female
sex, a past psychiatric history, lower functional status,
pain, smoking cessation, and higher regimen-related
toxicity [14].
There are only a few reports and studies addressing the
provision of psychological support or other supportive
interventions for patients with myeloablative chemother-
apy with or without ASCT:
In a large prospective randomized study using a new
media art intervention, McCabe and colleagues [15]
observed a positive effect on health related quality of
life. Also patients’ experiences and expectations of
having a stem cell transplant were positively influenced
[16].

Copyright © 2016 John Wiley & Sons, Ltd.


378
Gaston-Johansson et al. [17] emphasized the beneficial
effects of a comprehensive coping strategy (CCSP) on
the quality of life of patients with breast cancer who were
treated with HDC plus ASCT. The comprehensive coping
strategy included educational information, cognitive
restructuring, coping skills enhancement, and relaxation
with guided imagery.
Dimeo and colleagues [18] found that aerobic exercise
can reduce fatigue and improve psychological distress in
cancer patients undergoing HDC followed by ASCT.
They treated 27 patients with a bike training program of
30 min per day and compared them to a group without
training. An effect of exercise on life quality of patients
with ASCT was described by Courneya and colleagues
[19] and Baumann and colleagues [20]. Using a
multimodal exercise training during myeloablative
chemotherapy Oechsle and colleagues [21] showed
beneficial effects on physical performance, physical
functioning, and treatment-related symptoms.
Pain is a major symptom in patients undergoing
haematopoietic stem cell transplantation especially due
to injury of mucosal tissue [22,23]. Although the use of
analgetics is the main approach for treating this pain,
alternative approaches have been used to supplement the
efficacy of analgetics. Syrjala and colleagues [24,25]
tested the effects of stress management and cognitive-
behavioral skills, including relaxation training and guided
imagery and reported reduced pain levels.
Music and Music therapy are increasingly being used as
part of the psycho-oncological support and beneficial
effects on anxiety, mood, and pain were reported
[26,27]. So far, there is no overall theory about music
therapy with cancer patients. As specific functions, the
potential of self expression and taking action to regulate
self perception, relaxation, communication, and pain
reduction are stated [28]. The feeling of being capable of
acting is powerful in activating resources, stimulating
salutogenesis, and may so increase quality of live and
mood. Especially for patients undergoing HDC plus
ASCT expecting several adverse events (AE) and being
hospitalized for a longer time this might be beneficial.
Music therapy was part of an investigation concerning
the value of psychosocial support for patients receiving
HDC plus ASCT. The authors stated that music therapy
was well accepted and could be easily integrated into
the clinical context. Also the long term effects
concerning the improvement of pain coping strategies
were described [29].
To our knowledge, there is only one randomized
study investigating the effect of music therapy in
patients with HDC plus ASCT. Cassileth and colleagues
[30] showed that patients who received music therapy
had significantly fewer mood disturbances. Also, there
was a positive effect of music therapy on depression
and anxiety.
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G. Tuinmann et al.
The purpose of the presented study here was to evaluate
the effects of music therapy in addition to standard
treatment in patients undergoing HDC plus ASCT on
quality of life, anxiety, and depression. Also, any
differences in symptoms (especially pain), side effects,
medication use, and immunological changes were
measured. To our knowledge, this is the first European
randomized pilot study to investigate the effect of music
therapy on these parameters in cancer patients undergoing
HDC plus ASCT.
Patients and methods
This study was conducted from 03/2008 to 06/2012 at the
Department of Oncology and Hematology of the
University Medical Center Hamburg-Eppendorf. Every
patient undergoing high-dose chemotherapy followed by
ASCT was considered for eligibility. Inclusion criteria
were as follows: age above 18 years, patients with malig-
nancies (Non-Hodgkin-Lymphoma, Hodgkin Lymphoma,
Multiple Myeloma, Testicular Cancer, and Leukemia)
treated with HDC plus ASCT with an expected inpatient
stay longer than two weeks. Exclusion criteria were the
participation in other clinical trails, immobilization, brain
metastases, experiencing a severe psychotic episode, and
having major depression. Informed consent was obtained
from eligible patients. Patients were registered and
randomly assigned in our clinical trials facility to either
the music-therapy group (intervention group = IG) or
standard treatment (control group = CG). This study was
approved by the local ethics committee.
Music therapy was performed by a specially trained
music therapist. The first appointment was arranged
within two days after randomization. Music therapy was
administered two times per week for at least 20 min. This
seemed feasible for us with regard to the setting (oncology
ward). The intervention itself was neither planned nor
standardized, according to the expected individual coping
situation of each patient. Active (e.g., playing music and
singing) or receptive methods (e.g., listening to music)
were used, meeting the actual therapeutic needs. The
overall orientation in conducting the session was to build
up a therapeutical relationship first within a preliminary
talk about the patients feelings’ of the actual psychosocial
burden as well as his resources. According to the
upcoming topics and needs a specific music therapeutical
interaction was developed (e.g., expressing and modulat-
ing a certain mood through an improvisation in the
therapeutic dyad or defocusing from a painful experienced
symptom through listening to a resource stimulating
music). An ‘aftertalk’ to integrate the music experience
completed the session.
Patients in the CG had standard treatment (professional
care by physicians and nurses). They received psycho-
oncological support or medication when necessary.
Psycho-Oncology 26: 377–384 (2017)
DOI: 10.1002/pon

Music Therapy and stem cell transplantation
Measuring instruments
Quality of life was assessed using the EORTC QLQ-C30
at admission, every week, at discharge and after an
interval of 3 months. The global quality of life scale, the
emotional functioning and the pain scale were chosen for
the current study.
Patients’ functional state was assessed by an oncologist
with help of the Karnofsky Performance Score [31].
For exploration of anxiety and depression, we used the
Hospital Anxiety and Depression Scale (HADS) [32]. It
was completed at admission, every week, at discharge
and after an interval of 3 months. The questionnaire was
administered in German (HADS-D).
Regular blood samples were taken during the inpatient
period and were used for registration of side effects.
Additional blood samples were taken at admission and at
discharge [Immunoglobulin (Ig)-G, Ig-A, and lymphocyte-
subpopulations: T-helper cells (T4), T-suppressor cells
(T8), natural killer cells (NK)] to assess immunological
parameters.
AE and medication were assessed initially and through-
out the hospital stay. AE were scored as mild (grade I),
moderate (grade II), severe (grade III), life threatening or
disabling (grade IV), and death related (grade V)
according to the ‘common terminology criteria for adverse
events v3.0 (CTCAE)’.
Statistical analysis
Music therapy was expected to result in a quality of life
gain of 0.736 standard deviation (SD = 1) after three
weeks in comparison to standard therapy. A sample size
of 30 patients (α = 5%; beta = 20%, power = 80%) was
calculated. With an expected drop out rate of 10%, 33
patients were enrolled in both the intervention and control
arm. Baseline characteristics are presented for the
intention-to-treat (ITT) population, and according to treat-
ment assignment. Continuous variables are reported as
mean ± standard deviation and categorical variables are
presented as frequencies and percentages.
The primary outcome, EORTC quality of life, was
assessed in the ITT sample using an analysis of covariance
(ANCOVA) with treatment condition being the indepen-
dent variable and the difference in quality of life (post-
pre) being the dependent variable, adjusted for baseline
quality of life. Using an analogous analysis of covariance
approach differences in secondary study outcomes
between the treatment conditions were analyzed includ-
ing: EORTC subscales (emotional functioning and pain),
the Karnofsky performance score, the depression, and
anxiety score and blood parameters. Moreover, the occur-
rence of grade III to IV AE and any differences in pain,
anxiolytic, and anti-emetic medication in both groups
were analyzed using Pearson’s chi-squared test or Fisher’s
exact test, where appropriate. All data were analyzed on
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379
an ITT basis and additionally, a per-protocol (PP) analysis
was performed. These results were only reported if the
statistical significance differed from the ITT analyses.
For the follow up data a PP analysis was performed.
Missing values were replaced using a multiple imputation
approach according to the fully conditional specification
(FCS) method [33]. In all, 50 imputed data sets were created
and pooled analysis results are presented. A complete cases
(CC) analysis was further conducted as a sensitivity analysis.
A two-tailed p-value <0.05 was considered to be
statistically significant. However, secondary outcomes
were analysed in a strictly explorative way. No adjustment
for multiple testing was made, and they will be interpreted
in an explorative sense. All analyses were performed
using SPSS version 21.
Results
Recruitment started in March 2008 and finished in June
2012. During the recruitment period, 129 patients were
eligible (93 males/36 females) for the study. Of those,
14 had to be excluded, as they have already started their
treatment course or due to organizational reasons. Of these
115 patients, 66 (57.4%; 43 males/23 females) consented
to participate in the trial. Baseline characteristics were
similar in both treatment groups. However, when examin-
ing the underlying histology, more patients in the IG had
MM (70% versus 40% in the CG) (Table 1). As this
difference was significant in the ITT sample (p = 0.013),
we conducted a sensitivity analysis, adjusting all models
for the occurrence of MM. We found no such difference
in the PP sample (p = 0.218).
After randomization, six IG patients refused to continue
music therapy but gave their consent to remain in the
study. The reasons for discontinuation were the following:
impairment due to side effects (nausea, fatigue; n = 4),
annoyance regarding construction noise disturbing the
music experience (n = 1) and an unpleasant emotional
reaction (n = 1). Four patients had to be excluded after
randomization to the CG as a result of a secondary review
of the underlying histology of the cancer (intracerebral
NHL, Astrocytoma, embryonal Rhabdomyosarcoma,
Liposarcoma). However, each patient had received a
HDC plus ASCT. Three patients dropped out due to an
early death (n = 1), admission to an Intensive Care Unit
and death (n = 1) or withdrawal of consent (n = 1)
(Figure 1). A follow up PP analysis could be performed
on 53 patients. Patients in the IG had eight music
therapy sessions on average (min: 4/max: 17) lasting
50 min (min: 20/max: 50).
Primary outcome
In both groups, the rating of global life quality declined
from admission to discharge. Although the quality of life
Psycho-Oncology 26: 377–384 (2017)
DOI: 10.1002/pon
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380 G. Tuinmann et al.

Table 1. Baseline patient demographic and clinical characteristics Secondary outcomes

Music therapy Control
Characteristics (n = 33) (n = 33) EORTC – subscales
Gender, n(%) The emotional functioning scale scores improved in both
Male 20 (60.6%) 22 (66.7%) groups, with a slight, but not significantly, greater
Female 13 (39.4%) 11 (33.3%)
Age, mean ± SD 50.7 ± 14.6 50.5 ± 15.4
improvement in the IG (group difference 0.4 points,
Histology, n(%)
95% CI [ 7.5;8.3]; p = 0.924). The perception of pain
Hodgkin 1 (3%) improved significantly more in the IG (10.6 points,
Non-Hodgkin 3 (9%) 4 (12.12%) 95% CI [6.9;16.8]) in comparison to the CG (0.6 points,
Myeloma 23 (69.7%) 13 (39.4%) 95% CI [ 5.8;6.9]), p = 0.027 (Table 2).
Testicular cancer 7 (21.2%) 9 (27.3%)
Leukemia 2 (6.0%)
Karnofsky-Performance score (KPS)
Other: 4 (12.12%)
Length of hospital stay (days), mean ± SD 22.6 ± 6.0 23.1 ± 7.3 While the KPS score deteriorated from admission to
discharge in both groups, we found a smaller (not
significant) decline in the IG (group difference 0.8,
95% CI [ 2.2;3.9]; p = 0.596) (Table 2).

Hospital anxiety and depression scale (HADS)

In both groups the HADS depression-score increased and
the anxiety-score decreased. As the average score of both
groups did not exceed the cut-off, these findings were not
clinically relevant. The difference in change scores
between groups was not significant (depression p = 0.603
and anxiety p = 0.722) (Table 2).

Blood samples
As patients with MM have a disorder caused by a mono-
clonal proliferation of plasma cells, the differences in the
immunoglobulines were only analyzed for patients with
other histologies. In addition, patients who received
immunoglobulines (n = 3, CG) during their hospital stay
were excluded.
The concentration of IgG decreased slightly more in the
IG ( 1.8, 95% CI [ 3.4; 0.2]) than the CG ( 1.4,
95% CI [ 3.3;0.5]). IgA declined minimally in the IG
( 0.5, 95% CI [ 1.0;0.0]). However, the group
differences were not significant (Table 2).
The T4 count decreased a little less in the IG than the
CG (group difference 0.1, 95% CI [ 1.6;1.7];
p = 0.923).The T8 and NK decreased most in the IG.
These differences were not significant (Table 2).

Adverse events (AE)

Figure 1. Flow diagram of subject enrollment and progress
through the study
rating declined less in the IG in comparison to the CG (8.1
points, 95% CI [2.6;13.5] vs. 11.4 points, 95% CI
[5.9;16.8], respectively), the difference between the
groups was not significant (3.3 points, 95% CI
[–4.3;10.9]; p = 0.394) (Table 2).
The number of grade III to grade IV AE during patients’
inpatient stay was assessed. Leucopenia and Thrombopenia
were observed in all patients. Patients in the CG suffered
from infection, anemia, loss of appetite, nausea, diarrhea,
mucositis, and pain more often than the IG patients,
however only differences in mucositis and pain were
significant in the ITT sample (p = 0.005 and p = 0.040,
respectively). It is important to note that these differences
were no longer significant when adjusted for MM
(p = 0.065 and p = 0.269, respectively).

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology 26: 377–384 (2017)
DOI: 10.1002/pon
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Music Therapy and stem cell transplantation 381

Table 2. Primary and secondary outcomes in intention-to-treat (ITT) population – baseline-adjusted mean changes between admission and
discharge
Change from baseline, adjusted for baseline

Music therapy (n = 33) Control (n = 33) Total (n = 66) p-value

Global quality of life 8.1 [ 13.5; 2.6] 11.4 [ 16.8; 5.9] 3.3 [ 4.3;10.9] 0.394
Emotional Functioning 4.8 [ 0.8;10.4] 4.4 [ 1.3;10.1] 0.4 [ 7.5;8.3] 0.924
Pain 10.6 [ 16.8; 6.9] 0.6 [ 6.9;5.8] 10 [ 18.9; 1.2] 0.027
KPS 7.7 [ 9.8; 5.6] 8.5 [ 10.7; 6.4] 0.8 [ 2.2;3.9] 0.596
Depression 0.3 [ 0.7;1.3] 0.6 [ 0.4;1.6] 0.4 [ 1.8;1.0] 0.603
Anxiety 1.5 [ 2.6; 0.5] 1.2 [ 2.3; 0.2] 0.3 [ 1.8;1.2] 0.722
Ig-G (≠mm)* 1.8 [ 3.4; 0.2] 1.4 [ 3.3;0.5] 0.4 [ 2.9;2.1] 0.732
Ig-A (≠mm)* 0.5 [ 1.0;0.0] 0 [ 0.6;0.7] 0.5 [ 1.3;0.2] 0.177
T4 1.6 [ 2.8; 0.5] 1.7 [ 2.9; 0.5] 0.1 [ 1.6;1.7] 0.923
T8 1.1 [ 2.1; 0.2] 0.9 [ 1.9;0.1] 0.2 [ 1.5;1.1] 0.717
NK 0.6 [ 1.2; 0.1] 0.1 [ 0.7;0.5] 0.5 [ 1.3;0.3] 0.239

Abbreviations: KPS, Karnofsky-Performance score; Ig, Immunoglobulin; T4,T-helper cells; T8,T-suppressor cells; NK, natural killer cells.

In the PP population, differences were only significant Sensitivity analyses

for mucositis and not for pain (p = 0.011 and p = 0.076,
respectively). Overall (ITT-Analysis), CG patients had
significantly more grade III to IV AE (5.2 ± 2.4) compared
with patients of the IG (4.0 ± 1.7), p = 0.028. Again, this
finding was no longer significant when adjusting for
MM in the ITT (p = 0.228) and the PP populations
(p = 0.057) (Table 3).
Medication
Aprepitant (antiemetic medication) was administered
significantly more often in the CG (p = 0.040). Otherwise
no significant differences between the groups were
observed. Only seven patients (n = 4, IG; n = 3, CG) took
antidepressants, so differences between the groups were
negligible (Table 4).
Results of our complete cases sensitivity analyses were in
accordance with the results of the ITT and PP analyses
using multiple imputations (data not shown).
Follow up
Patients were asked to complete the EORTC-QLQ-C30
and HADS-D questionnaire three months after discharge.
A PP analysis could be performed on 29 patients
(Figure 1). Compared with the value at discharge, the
quality of life improved in both groups with a larger (but
not significant) improvement in the IG (n = 15) in
comparison to the CG (n = 14) (12.9 points, 95% CI
[1.7;24.1] vs. 8.6 points, 95% CI [ 0.4;17.6]; p = 0.598).
Compared with discharge, emotional functioning scale

Table 3. Grade III to IV adverse events (AE) (n.p. = not possible)

Adverse event (3/4°) Music therapy (n = 33) Control (n = 33) Total (n = 66) p-value p-value*
b
Neutropenia [n(%)] 33 (100.0) 32 (97.0) 65 (98.5) 1.000 n.p.
Thrombopenia [n(%)] 33 (100.0) 32 (97.0) 65 (98.5) 1.000b n.p.
Infection [n(%)] 23 (69.7) 26 (78.8) 49 (74.2) 0.398a 0.826
Anemia [n(%)] 20 (60.6) 23 (69.7) 43 (65.2) 0.438a 0.681
Loss of appetite [n(%)] 5 (15.2) 11 (33.3) 16 (24.2) 0.085a 0.139
Mucositis [n(%)] 2 (6.1) 11 (33.3) 13 (19.7) 0.005a 0.065
Pain [n(%)] 4 (12.1) 11 (33.3) 15 (22.7) 0.040a 0.269
Nausea [n(%)] 5 (15.2) 7 (21.2) 12 (18.2) 0.523a 0.879
Diarrhea [n(%)] 1 (3.0) 5 (15.2) 6 (9.1) 0.197b n.p.
Weakness [n(%)] 4 (12.1) 7 (21.2) 11 (16.7) 0.322a 0.838
Liver toxicity [n(%)] 2 (6.1) 3 (9.1) 5 (7.6) 1.000b n.p.
Hypokalaemia [n(%)] 1 (3.0) 3 (9.1) 4 (6.1) 0.613b 0.491
c
Overall number of AEs (Mean ± SD) 4.0 (±1.7) 5.2 (±2.4) 4.6 (±2.2) 0.028 0.228

*Model adjusted for Myeloma (resulting from logistic or linear regression)

2
a
The p-value based on pearsons Chi test
b
The p-value based on fishers exact test
C
The p-value based on t-test

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology 26: 377–384 (2017)
DOI: 10.1002/pon
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382 G. Tuinmann et al.

Table 4. Patients with medication during hospital stay and median daily dosage (with inter quartile range (IQR))
Music therapy (n = 33) Control (n = 33) Total (n = 66) p-value

Aprepitant n (%) 4 (12.1) 11 (33.3) 15 (22.7) 0.040a

Median [IQR] 15.5 [13.3;16.8] 15.8 [11.4;17.8] 15.8 [11.9;17.4]
Metoclopramide n (%) 26 (78.8) 23 (69.7) 49 (74.2) 0.398a
Median [IQR] 4.0 [1.0;14.5] 5 [0.7;15.9] 4.4 [0.9;14.6]
Morphin n (%) 7 (21.2) 9 (27.3) 16 (24.2) 0.566a
Median [IQR] 20.7 [8.2;40.5] 6.6 [2.9;11.0] 11.0 [3.9;24.2]
Metamizol n (%) 8 (24.2) 12 (36.4) 20 (30.3) 0.284a
Median [IQR] 194.7 [57.4;2421.4] 376.5 [49.3;816.7] 234.4 [50.4;1421.4]
Paracetamol n (%) 18 (54.5) 22 (66.7) 40 (60.6) 0.314a
Median [IQR] 111.5 [50.0;272.7] 130.1 [62.5;175.0] 116.0 [51.3;195.1]
Tramadolon n (%) 6 (18.2) 2 (6.1) 8 (12.1) 0.258b
Median [IQR] 63.6 [3.4;205.7] 104.7 [9.4;200.0] 63.6 [6.4;202.9]
Lenogastrim n (%) 7 (21.2) 11 (33.3) 18 (27.3) 0.269a
Median [IQR] 0.05 [0.01;0.08] 0.07 [0.04;0.12] 0.05 [0.02;0.11]
Filgastrim n (%) 15 (45.5) 12 (36.4) 27 (40.9) 0.453a
Median [IQR] 0.25 [0.18;0.30] 0.24 [0.18;0.30] 0.25 [0.18;0.30]
Blood Transfusion n (%) 25 (75.8) 27 (81.8) 52 (78.8) 0.547a
Median [IQR] 0.11 [0.10;0.16] 0.13 [0.10;0.20] 0.12 [0.10;0.18]
2
The p-value based on pearsons Chi test
a

The p-value based on fishers exact test

b

scores slightly increased in the IG (0.3 points, 95% CI
[ 10.9;11.5]) while they decreased in the CG ( 3.0
points, 95% CI [ 12.1;6.1]; p = 0.647).
While the perception of pain showed a tendency to
increase after 3 months in the IG (12.2 points, 95% CI
[ 5.1;29.5]) it decreased in the CG ( 7.6 points, 95%
CI [ 21.0;5.8]; p = 0.085).
In both groups, the HADS depression-score decreased
over the three months (IG 0.6, 95% CI [ 1.9;0.7],
CG 0.4, 95% CI [ 1.4;0.7]; p = 0.752). In contrast, the
anxiety-scores increased (IG 1.1, 95% CI [ 0.6;2.7],
CG 1.3, 95% CI [0.0;2.6]; p = 0.799). As the overall
score of both subscales did not exceed the cut-off, these
findings were also not clinically relevant.
Discussion
This study was performed to investigate the potential
effects of music therapy as supportive care in patients
who were treated with HDC and ASCT. We were
especially interested whether music therapy could
improve patients’ quality of life and psychological well
being as well as to reduce side effects of the chemothera-
peutic treatment. In addition, we wanted to investigate
potential immunological changes due to music therapy.
Despite of some findings that support the effect of music
therapy, our results are preliminary. This is to due the
limitations of our study (e.g., single institution with
predominantly one music therapist; rate of drop outs and
lost to follow up), the missing data and the statistical
overestimation of the effect of our intervention on global
quality of life leading to a too small sample size. There-
fore, despite positive changes, only a few significant
findings can be reported in an explorative sense.
In this regard, according to our primary outcome, we
observed a small but not significant difference in global
quality of life (IG > CG), which lasted to the follow up
evaluation. In contrast, the pain perception scores changed
significantly in the IG compared with the CG. This is very
meaningful, as patients do suffer immensely from pain
due to mucosal damage. There were also significant
differences in the overall number of side effects and in
antiemetic medication use between the groups. Interest-
ingly, IG patients had significantly less pain and mucosi-
tis. However, when adjusted for MM (n = 36) this result
was no longer significant.
Aprepitant (as an antiemetic treatment) was adminis-
tered significantly more often in the control group.
Thorton et al. [34] could show that psychological
interventions in cancer patients reduce inflammatory
markers especially in depressed patients. No significant
changes of the immune function parameters determined
in this study were observed. This may be due to the small
sample size, the missing values or the only moderate
distress in our patient groups. IgA is known to prevent
infections in the upper respiratory system [35]. The IgA
value at discharge was slightly better and the infection rate
lower in the IG, however, these findings were possibly
coincidental. The same applies to the improved
T4/T8 T-cell ratio in the IG.
We did not find the emotional distress that we had
expected. In fact, in contrast to previous observations,
most of the patients undergoing ASCT were neither
depressed nor anxious. Consequently, no significant
differences among the groups were observed. In the previ-
ous randomized study with music therapy [30] a similar
finding was described. The authors reported of a little
effect on depression, as the depression scores were

Copyright © 2016 John Wiley & Sons, Ltd. Psycho-Oncology 26: 377–384 (2017)
DOI: 10.1002/pon
 10991611, 2017, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/pon.4142 by Johns Hopkins University, Wiley Online Library on [23/04/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Music Therapy and stem cell transplantation 383

surprisingly low. They did not find a significant change
during the treatment.
An explanation might be, that the patients have
manageable side effects and positive expectations
concerning the result of the treatment [36]. In their
collective Braamse at al. [37] reported of a prevalence rate
of elevated anxiety and depressive symptoms at baseline
of 6,5% and 7,5%, respectively, which is lower than in
other studies [11,13].
These findings come close to our experience listening to
the patients. We were often told that the transplantation is
associated with a deep positive feeling of hope to survive.
Also patients reported that they had built-up positive
cognitive strategies in advance in a hope to have a helpful
defense.
Qualitative investigations are needed to prove these
hypotheses. There is especially a need to carefully
determine the specific aspects of distress that are relevant
to ASCT-inpatients, and to determine whether and how
music therapy is able to address these specific aspects.
We note that Music Therapy was offered in an individual
and process orientated supportive intention. As performed
in this study, we suggest a perspective of investigating
Music Therapy as a whole complex, considering the use
of music in a therapeutic relationship as the ‘overall
healing factor’, rather than investigating certain isolated
aspects. In this perspective, we also acknowledge that
there is a need of further research to determine the
underlying specific therapeutic factors (e.g., therapeutical
relationship, coping style/type, etc.) more clearly.
Summary
In cancer treatment, the issue of quality of life is becoming
more important [16]. Given this, any approach to increase
quality of life in patients with HDC plus ASCT should be
supported. This may also be the case for music therapy as
a supportive measure, as we identified positive effects on
pain perception, as well as an improvement of symptoms
and antiemetic medication. As our findings are preliminary
and just variably reach statistical significance, studies with
larger sample sizes, probably within a multi-center trial
design could be helpful.
Acknowledgements
This study was sponsored by the ‘Else-Kröner-Fresenius-Stiftung’
from 01.11.2008-31.10.2010 (P33/08//A19/08) and 01.11.2010-
31.10.2012 (P23/10//A34/10)
Conflict of Interest
The authors have declared that there is no conflict of
interest.

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