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European Journal of Integrative Medicine 5 (2013) 438442

Original article

Music therapy and emotional expression during chemotherapy. How do

breast cancer patients feel?
Francesca Romito a, , Fulvia Lagattolla a , Carla Costanzo a , Francesco Giotta b , Vittorio Mattioli c
a

Experimental Unit of Psycho-Oncology, Department of Critical Area and Surgery, National Cancer Research Center Istituto Tumori Giovanni Paolo II,
Via O. Flacco 65, 70125 Bari, Italy
b Department of Experimental and Medical Oncology, National Cancer Research Center Istituto Tumori Giovanni Paolo II, Via O. Flacco 65, 70125 Bari, Italy
c Department of Critical Area and Surgery, National Cancer Research Center Istituto Tumori Giovanni Paolo II, Via O. Flacco 65, 70125 Bari, Italy
Received 14 November 2012; received in revised form 10 April 2013; accepted 14 April 2013

Abstract
Introduction: Psychological distress, suffering and negative emotions are commonly experienced by breast cancer patients during the course of
their illness. The present study aims to measure the efficacy of an integrative intervention of music therapy and emotional expression on lowering
negative emotions in breast cancer patients during chemotherapy administration.
Methodology: Sixty-two breast cancer patients were recruited in the outpatient Oncology Unit, and were randomly assigned to either the
experimental or the control arms of the study.
The experimental group (N = 31) received a single integrated intervention of music therapy and emotional expression in group format during the
infusion of chemotherapy. The control group (N = 31) received standard psychosocial care. The Emotion Thermometers tool was administered
before and after the intervention. This tool is a combination of visual scales which measure stress, anxiety, depression and anger. It also includes
a need for help variable.
Results: The experimental group had significant reductions in stress, anxiety, depression and anger (p < 0.05, Cohens d > 50 for all variables).
Anxiety and stress were reduced also in the control group, but the effect size was small (p < 0.05, Cohens d < 50). Patients in the experimental
group were more satisfied in their need for help than the control group (p < 0.001, Cohens d > 80).
Discussion: The integrative intervention has been rated helpful by women with cancer and can be considered useful in lowering negative emotions
during the administration of chemotherapy, in particular anger and depression. The limitations of this study and future research directions are
discussed.
2013 Elsevier GmbH. All rights reserved.
Keywords: Cancer; Chemotherapy; Complementary therapies; Music therapy; Psychological distress

Introduction
The psychological discomfort experienced by cancer patients
is not closely correlated to their vulnerability or susceptibility
to psychopathologies. Quite the contrary, it is ascribable to the
situation of crisis brought about by cancer as an unexpected
event.
This psychological discomfort, usually referred to as distress,
is a multifactorial condition which develops as a continuum,
from common feelings of vulnerability, sadness and fear to

Corresponding author. Tel.: +39 0805555328.

E-mail address: francescaromito@yahoo.com (F. Romito).

1876-3820/$ see front matter 2013 Elsevier GmbH. All rights reserved.
http://dx.doi.org/10.1016/j.eujim.2013.04.001

more disabling conditions and fully fledged psychiatric disorders, including generalized anxiety, panic attacks and major
depression [1].
Around 2040% of all cancer patients exhibit a state of distress induced by their condition [2]. In general, women exhibit
higher levels of distress than men [3]. The state of distress is
heavily correlated to depression and anxiety, as well as to a low
level of emotional expression [4]. The level of distress is particularly elevated during the phases immediately after diagnosis as
well as during chemotherapy [5].
Patients with psychological distress at a subclinical level have
been shown to resort to complementary and alternative medicine
[6] more frequently than the general population. For instance,
breast cancer patients often resort to complementary treatments,

F. Romito et al. / European Journal of Integrative Medicine 5 (2013) 438442

including diet supplements, relaxation techniques and self-help

groups [7]. Over the last few years, music therapy has become
a complementary therapy in the clinical treatment of patients
undergoing both medical and surgical procedures [8,9]. What is
more, the use of music therapy is gradually growing in popularity as a treatment option made available to cancer patients in
hospitals [10].
Music therapy is recognized as a complementary, evidencebased treatment which aims to improve the quality of life of
cancer patients [13,14]. It has now become an integral part of
the CAM (Complementary and Alternative Medicine) programs
aimed at cancer patients [11,12].
Regular music therapy has been found to be useful for
promoting autonomic cardiovascular function in breast cancer patients; this kind of intervention seems to help these
patients control the progression and relieve symptoms of cardiac
damage which occurs as a result of treatment with anthracyclinecontaining chemotherapy [15]. In a single case study Ko et al.
demonstrated that an active form of music therapy based on
traditional oriental medicine theory and focused on the equilibrium between the body and the mind might be an alternative
treatment for chronic fatigue, as this type of therapy proves able
to normalize the levels of cortisol in the treated patient [16].
In addition, sharing and expressing emotions in a group has
been shown to contribute to a better adaptation to both disease
and treatment [17]. Whereas most studies in the literature have
concentrated on pure music therapy interventions as CAM, the
present study aims instead to test the efficacy of an experimental
approach in complementary cancer care, a single group session
of music therapy [13] combined with emotional expression,
in managing negative emotional experiences including anxiety,
depression, anger and stress, in a group of women receiving
chemotherapy at a cancer clinic.

Methods
Sample
Sixty-two breast cancer patients receiving chemotherapy as
outpatients in the Experimental and Medical Oncology Department of the National Cancer Research Center Istituto Tumori
Giovanni Paolo II of Bari, Italy (NCRC Bari), were enrolled in
this study. Inclusion criteria included: diagnosis of breast cancer; currently undergoing chemotherapy treatment; 2075 years
old; absence of auditory/visual deficits and a good understanding
of Italian. Female outpatients who had other cancer diagnoses,
who were not undergoing chemotherapy, who were outside the
defined age range 1975 years old, had auditory or visual deficits
or who were not able to fully understand the Italian language
were excluded from the study. Demographic and clinical data
were collected through clinical records.
The patients gave informed consent to participate and were
quasi-randomly assigned to the experimental and control arms
of the study. The study followed the ethical requirements of the
Helsinki Declaration and was approved by the ethics committee
of NCRC Bari.

439

Study procedure
The study was conducted during a 1-month time frame.
Patients were visited, as usual, by their oncologists before the
administration of chemotherapy, and then informed by the oncology nurse of the possibility to participate in the study. On
Mondays and Wednesdays of each week, the first consecutive
eligible patients of the day who gave their informed consent
to participate in the study were placed in the same room for
chemotherapy infusion and took part in the experimental group.
On Tuesdays and Thursdays the same procedure was followed
and these patients were assigned to the control groups. 31
patients were allocated to the experimental group and 31 to the
control group.
Methodology
The 31 breast cancer patients in the experimental group were
divided into a total of seven separate groups of 45 participants
each. Each group underwent a single session of music therapy
and emotional expression (hereinafter referred to as integrative
MT) administered at the cancer clinic during chemotherapy.
Each session, which lasted about 2.5 h, was jointly directed by
a music therapist and a clinical psychologist.
The music therapy (music therapy in the globality of
languages) [18] intervention envisages listening to music, relaxation and picture visualization, and activation of synaesthesias
by means of pictures, sounds and autobiographical narrative.
The integrative MT session was carried out by means of
various Vocal Holding techniques [19]: patients introduced
themselves by beginning to sing their names with the voice support and accompaniment of the music therapist. They were then
guided to start singing musical refrains which represented their
own identity and musical memories to dedicate to themselves
and to the other women of the group. This Vocal Mantra allowed
the group of patients to sing in unison thus giving rise to a sense
of belonging and empathic sharing based on their interlacing
voices.
To facilitate verbal expression, patients were asked to give
their comment on and choose their favorite among several
evocative pictures (e.g. maternity, couples, natural elements,
mythological pictures, seasons, life cycle) shown to the group.
Swing-style music backgrounds [20] in a repetitive binary
rhythm created a welcoming atmosphere. Comments and picture choices, along with verbal exploration of the emotions felt
during the group vocal experience, allowed for openness and
sharing of emotions within the group. The final step consisted
of leaving verbal traces (creative journaling to help other women
who were to start chemo) and non-verbal traces (creative patchworks of selected pictures). These writings have not been used
for qualitative analyses.
As with the experimental group, the 31 breast cancer patients
in the control group were divided into 7 groups of 45 participants each for the session of chemotherapy. A hospital
volunteer engaged these patients in a brief one-to-one conversation (around 20 min). The volunteer was trained to listen to
what the patients were willing to talk about (e.g. their everyday

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F. Romito et al. / European Journal of Integrative Medicine 5 (2013) 438442

life, their family relationships or also simple cooking recipes)

and to reassure patients about their possible worries but without focusing too much on the emotional aspects that the patients
may have brought up. The volunteer was not a psychologist. The
aim of the intervention carried out by the volunteer was to help
patients feel comfortable and welcomed.
Tools
The Emotion Thermometers Tool was used for quantitative
assessment [21]. This tool is a combination of five visual scales
(110) which measure four emotions (stress, anxiety, depression, and anger) and includes a need for help variable. This
tool has been previously validated in oncology setting [21].
This variable, administered after the session, is used to measure the perceived efficacy of the help received. The tool was
administered to all women (experimental group and controls)
by the same trained clinical psychologist before and after their
chemotherapy infusion.
Statistical analysis
The characteristics of the experimental and control groups
were compared (inter-group analyses) using the T test for continuous variables (age and Emotion Thermometers) and the 2
test for categorical variables (marital status, employment, disease and surgery). These analyses were carried out to verify the
similarity of the two groups. The efficacy of the integrative MT
session was evaluated by comparing the measurements of the
Emotion Thermometers tool before and after the intervention in
both the experimental and the control group (intra-group analyses): this was performed with the T test and the magnitude of
the effect was calculated using Cohens d. Effect sizes is used
to quantitatively describe the size of an effect.
Values of p < 0.05 were deemed to be statistically significant.
SPSS statistics software V.17.0 was used for all analyses.
Results
The average age of the 31 women in the experimental sample
was 54 years. 81% were married, and 19% were unmarried.
Only 13% of the sample worked, the remaining patients being
housewives. 90% were undergoing adjuvant treatment, and 10%
had breast cancer metastases. 77% had undergone a mastectomy
while 23% had undergone lumpectomy (Table 1).
The average age of the 31 control group women was also
54 years. 90% of them were married, and 10% unmarried. Only
16% of them worked, the remaining patients being either housewives or retired. 71% were undergoing adjuvant treatment, and
29% had breast cancer metastases. 65% of the control sample
had undergone a mastectomy while 25% had undergone lumpectomy. The remaining 10% did not provide any information in this
regard (Table 1). The experimental group and the control group
were comparable on both their socio-demographic and clinical
features (Table 1).
Before the integrative MT session the experimental sample
exhibited the following levels on the Emotion Thermometer:

Table 1
Clinical and socio-demographic features of experimental group and control
group.

Average age
Marital status
Married
Unmarried
Employment
Employed
Housewife
Disease
Localized tumor
Metastatic tumor
Surgery
Lumpectomy
Mastectomy

Experimental group,
N (31)

Control group,
N (31)

54.14

54.21

0.981

25 (81%)
6 (19%)

28 (90%)
3 (10%)

0.279

4 (13%)
27 (87%)

5 (16%)
26 (84%)

0.574

28 (90%)
3 (10%)

22 (71%)
9 (29%)

0.054

7 (23%)
24 (77%)

8 (25%)
20 (65%)
10% missing
data

0.629

Table 2
Emotion Thermometers tool mean values before integrative MT session.

Stress
Anxiety
Depression
Anger
Need for help

Experimental group

Control group

5.6
5.9
4.1
4.7
6.5

4.5
4.5
2.7
3.6
5.8

0.212
0.125
0.118
0.322
0.428

stress mean (M) = 5.6, anxiety M = 5.9, depression M = 4.1,

anger M = 4.7 and need for help M = 6.5 (Table 2, Fig. 1). The
control sample exhibited the following baseline levels: stress
M = 4.5, anxiety M = 4.5, depression M = 2.7, anger M = 3.6
and need for help M = 5.8. Analysis of these emotional features
assessed at baseline did not show significant differences
between the two groups (inter-group analyses: T test p > 0.05
for all variables) (Table 2).
The levels of the Emotion Thermometers as measured after
the integrative MT session are shown in Table 3. The differences

Fig. 1. Emotion Thermometers tool pre- and post-integrative session in the

experimental group.

F. Romito et al. / European Journal of Integrative Medicine 5 (2013) 438442

Table 3
Emotion Thermometers tool pre- and post-integrative MT session in the two
groups.
Experimental group

Stress
Anxiety
Depression
Anger

Control group

Pre

Post

Pre

Post

5.6
5.9
4.1
4.7

3.3
3.3
2.3
2.4

0.036
0.026
0.000
0.000

0.62
0.69
0.52
0.58

4.5
4.5
2.7
3.6

3.8
3.5
2.5
3.3

0.002
0.004
0.822
0.863

0.29
0.39
0.05
0.04

between the pre- and post-integrative MT session means were

found to be statistically significant for all the variables measured
(intra-group analyses: T test p < 0.05), and Cohens d effect size
was calculated. The effect size was medium for all measures
included. In the control group however, only the drop in the levels
of stress and anxiety (p < 0.005) turned out to be statistically
significant, even if the effect size was small (Table 3).
The perceived efficacy of the intervention received was higher
in the group that received the integrative MT (M = 8.3) compared
to the control group (M = 3.3) (p < 0.001, Cohens d 1.59, huge
effect size).
All women left a trace of their experience in a journal ideally
destined to help other women who are about to start chemotherapy. Most of patients expressed great appreciation for the group
experience, recognizing the positive impact of singing together,
listening to sounds from instruments, and using tools meant to
facilitate autobiographical narrative. They commented that the
duration of the chemotherapy session appeared shorter. Here we
report a short contribution by one of the women who participated
in the study. We have chosen this text to offer readers an idea of
how the cancer experience can be perceived as a challenge but
also as an opportunity in resilient cancer patients:
In life there are things you look for and things that come up
you would never wish to see!
And you are not the same as you used to be. . .
You may run away and leave everything behind, or stop and
face problems.
The only certainty is that you will never again be the same
as you used to be, but you are given an option: to become a
better and stronger woman, more open and grateful to life for
what every new day may bring (Giovanna, 52 years old).
Discussion
The integrative therapy session had a positive impact on all
the parameters under study, and in particular satisfied the parameter perceived efficacy of help received significantly more than
the volunteer care with medium to huge effect size. The control
group also exhibited a significant reduction of stress and anxiety
after the standard volunteer care, but the effect size was small
and the levels of depression and anger remained unchanged. A
recent systematic review showed that music therapy is effective
in improving mood in cancer patients [22]. Furthermore, in a
specific sample of breast cancer patients undergoing radical mastectomy it lowered depression [23]. To the best of our knowledge

441

no previous reports have documented any effect of music therapy

on anger in cancer patients. However, interventions comprising percussion instruments as an aid to psychotherapy treatment
have positively treated anger and aggressive behavior in male
adolescents [24], and various types of musical therapy interventions have shown to lower anger and other negative emotions in
young females in a substance abuse rehabilitation program [25].
The interest of the present integrative intervention lies in the
fact that it combines music therapy techniques with the sharing of emotions in a group, induced by evocative pictures. The
women in the groups were most drawn to pictures showing
animal symbols (e.g. a lion for bravery), tender physical contact (e.g. embraces), life metaphors (e.g. the cycle of seasons),
and journey settings (e.g. a bridge over a river). The symbolic
language of music and evocative pictures allows access to the
intimate world of emotions and may more readily overcome
denial-based defenses, opening the door to communication and
sharing at times of stress and emotional fragmentation. Emotional sharing amongst women with the same illness may offer
them the opportunity to feel less unfortunate and isolated and to
feel reassured about the normality of their reactions to the disease. All these positive feelings may help individuals to feel less
angry and depressed. Another possible explanation relates to the
humanization factor: finding alternative therapies available in
the hospital may help patients to feel welcomed and reassured.
Many patients have written in the journal that they have
perceived the duration of the chemotherapy session being
shorter, as also reported by other studies [17], and they also
felt supported and warmly received within the chemotherapeutic
setting.
The main limitation of the present study is that although the
single session intervention has proven its efficacy in the short
term, it would have been interesting to see whether the changes
in emotions remained stable over a longer time frame, e.g. 1 or
2 weeks.
Other limitations of the study were the relatively small sample size and the tool used to measure the emotional outcomes.
Although validated, the Emotion Thermometers tool has been
used as a unique outcome measure, whereas in other studies it has
been used in comparison with other questionnaires [e.g. 26]. For
future research it would be useful to widen the assessment of the
efficacy of music therapy combined with emotional expression
to an entire cycle of 45 sessions in order to check whether the
improvement in emotional parameters remains stable over time
and at follow up. Moreover, while, the present study has evaluated the role of MT and emotional expression as an integrative
intervention, future research may focus on the understanding of
the efficacy of either music therapy or emotional expression in
women undergoing chemotherapy.
In conclusion, the integrative intervention reported in this
paper has been rated helpful by women with cancer. It can
be considered useful in lowering negative emotions during
the administration of chemotherapy, in particular anger and
depression which are emotions that negatively affect psychological well-being. Given that patients consider the moment of
chemotherapy administration to be very stressful, this relatively
simple intervention could be offered to relieve patients negative

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F. Romito et al. / European Journal of Integrative Medicine 5 (2013) 438442

feelings. A study with a higher number of patients and more

sessions would however permit a better evaluation of the efficacy
of this treatment.
Conict of interest statement
The authors declare that there is no conflict of interest.
Acknowledgments
The authors thank Angelo Paradiso, Scientific Director of
NCRC Bari, and Giuseppe Colucci, former Head of the Department of Experimental and Medical Oncology at NCRC of Bari,
for their support in the development and realization of the present
project of integrative music therapy and emotional expression.
The authors acknowledgments also go to Caroline Oakley for
her assistance with linguistic revision of the paper.
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