Integrative Non-Pharmacological Interventions for Anxiety Management in Chemotherapy Patients: A Systematic Review
Abstract
Abstract
Background: Anxiety is a prevalent and debilitating symptom among cancer patients undergoing chemotherapy. Pharmacological anxiolytics can produce undesirable side‑effects and may interact with cancer treatments. Consequently, research has explored non‑pharmacological interventions—such as mindfulness‑based interventions, cognitive–behavioural and acceptance therapies, relaxation practices, and complementary modalities—to reduce anxiety. This review critically evaluates randomized controlled trials (RCTs) and systematic reviews published between 2016 and 2025 on non‑pharmacological interventions for chemotherapy‑related anxiety.
Methods: A systematic search of PubMed, Scopus, Web of Science, and Google Scholar (January 2016–September 2025) identified RCTs and meta-analyses on non-pharmacological interventions for anxiety in adult cancer patients receiving chemotherapy or survivors. Non-randomized, pharmacological, and pediatric studies were excluded. Two reviewers independently extracted data on samples, interventions, outcomes, and effect sizes. RCT quality was assessed using Cochrane’s risk-of-bias tool.
Results: Twenty-three studies (14 RCTs and nine reviews) met inclusion criteria, evaluating mindfulness-based stress reduction (MBSR), acceptance and commitment therapy (ACT), cognitive behavioral therapy (CBT), virtual reality (VR), music therapy, relaxation techniques, aromatherapy, gratitude or behavioral activation, Tai Chi/Qigong, hypnosis, acupuncture, and reflexology. MBSR showed the strongest effects, reducing distress (SMD = –1.35) and anxiety (SMD = –1.48) and improving self-efficacy. ACT and CBT achieved small-to-moderate anxiety reductions (SMD = –0.41 and –0.61). VR alleviated anxiety, pain, and stress, while music therapy alone or combined with relaxation significantly reduced anxiety and depression. Aromatherapy and gratitude-based interventions yielded modest benefits, whereas Tai Chi/Qigong (SMD = –0.99) and hypnosis improved anxiety. Guidelines recommend MBIs, yoga, hypnosis, relaxation, music, and lavender oil during treatment, and MBIs, yoga, acupuncture, Tai Chi/Qigong, and reflexology post-treatment.
Conclusions: Non-pharmacological interventions offer promising adjuncts for chemotherapy-related anxiety. Strong evidence supports mindfulness-based therapies, ACT, CBT, VR, music therapy, relaxation, aromatherapy, and gratitude practices. Tai Chi/Qigong and hypnosis show emerging benefits, while evidence for reflexology and acupuncture remains limited. Integration should reflect patient preferences and resource availability. Future research needs standardized outcomes, larger trials, and combined approaches to strengthen evidence and optimize supportive care in oncology.
References
Carlson, L. E., Ismaila, N., Addington, E. L., Asher, G. N., Atreya, C., Balneaves, L. G., Bradt, J., Fuller-Shavel, N., Goodman, J., Hoffman, C. J., Huston, A., Mehta, A., Paller, C. J., Richardson, K., Seely, D., Siwik, C. J., Temel, J. S., & Rowland, J. H. (2023). Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology–ASCO guideline. Journal of Clinical Oncology, 41(28), 4562–4591. https://doi.org/10.1200/JCO.23.00972
Chirico, A., Maiorano, P., Indovina, P., Milanese, C., Giordano, G. G., Alivernini, F., Iodice, G., Gallo, L., De Pietro, G., Lucidi, F., Botti, G., De Laurentiis, M., & Giordano, A. (2020). Virtual reality and music therapy as distraction interventions to alleviate anxiety and improve mood states in breast cancer patients during chemotherapy. Journal of Cellular Physiology, 235(6), 5353–5362. https://doi.org/10.1002/jcp.29422
Gatti, F., Perego, G., Milano, F., Calleri, G., Giurioli, B., & Di Mattei, V. E. (2025). The effects of online yoga practice on cancer patients: A systematic review. Healthcare, 13(3), 225. https://doi.org/10.3390/healthcare13030225
Gezgin Yazıcı, H., Ökten, Ç., Karabulut, E., & Aliustaoğlu, M. (2024). Effect of music on anxiety and fatigue in cancer patients undergoing chemotherapy: A randomized controlled trial. Archives of Iranian Medicine, 27(11), 611–617. https://doi.org/10.34172/aim.31258
Han, Q. Q., Fu, Y., Le, J. M., Ma, Y. J., Wei, X. D., Ji, H. L., Jiang, H., Gao, Y., & Wu, H. (2021). The therapeutic effects of acupuncture and electroacupuncture on cancer-related symptoms and side-effects. Journal of Cancer, 12(23), 7003–7009. https://doi.org/10.7150/jca.55803
Jiang, X., Sun, J., Song, R., Wang, Y., Li, J., & Shi, R. (2024). Acceptance and commitment therapy reduces psychological distress in patients with cancer: A systematic review and meta-analysis of randomized controlled trials. Frontiers in Psychology, 14, 1253266. https://doi.org/10.3389/fpsyg.2023.1253266
Li, D., Li, Y. X., Bai, X., Wang, M. J., Yan, J. Z., & Cao, Y. J. (2022). The effects of aromatherapy on anxiety and depression in people with cancer: A systematic review and meta-analysis. Frontiers in Public Health, 10, 853056. https://doi.org/10.3389/fpubh.2022.853056
Nguyen, K. T., Chan, D. N. S., Cheung, A. T., Hoang, H. T. X., Truong, A. T., Chow, K. M., Choi, K. C., & Chan, C. W. H. (2025). Randomised controlled trial of music listening combined with progressive muscle relaxation for mood management in women receiving chemotherapy for cancer. Supportive Care in Cancer, 33(3), 245. https://doi.org/10.1007/s00520-025-09281-4
Riba, M. B., Donovan, K. A., Andersen, B., Braun, I., Breitbart, W. S., Brewer, B. W., Buchmann, L. O., Clark, M. M., Collins, M., Corbett, C., Fleishman, S., Garcia, S., Greenberg, D. B., Handzo, R. G. F., Hoofring, L., Huang, C. H., Lally, R., Martin, S., McGuffey, L., Mitchell, W., … Darlow, S. D. (2019). Distress management, version 3.2019, NCCN clinical practice guidelines in oncology. Journal of the National Comprehensive Cancer Network, 17(10), 1229–1249. https://doi.org/10.6004/jnccn.2019.0048
Shariatmadari, H., Taheri-Kharameh, Z., Kamaliuon, N., & et al. (2025). Comparing the effectiveness of gratitude intervention and behavioral activation technique in breast cancer patients: A randomized trial. BMC Cancer, 25, 1226. https://doi.org/10.1186/s12885-025-14492-3
Tian, X., Yi, L.-J., Liang, C.-S.-S., Gu, L., Peng, C., Chen, G.-H., & Jiménez-Herrera, M. F. (2022). The impact of mindfulness-based stress reduction (MBSR) on psychological outcomes and quality of life in patients with lung cancer: A meta-analysis. Frontiers in Psychology, 13, 901247. https://doi.org/10.3389/fpsyg.2022.901247
Vayne-Bossert, P. (2024). Hypnosis for symptom management in adult cancer patients: What is the evidence? Current Treatment Options in Oncology, 25(3), 364–375. https://doi.org/10.1007/s11864-023-01168-y
Wang, X., Li, W., Zhao, T., Jin, Q., & Wang, H. (2025). Cognitive behavioral therapy’s impact on anxiety, depression, and quality of life in patients with head and neck cancer: A systematic review. Frontiers in Psychology, 16, 1547999. https://doi.org/10.3389/fpsyg.2025.1547999
Wyatt, G., Lehto, R., Guha-Niyogi, P., Brewer, S., Victorson, D., Pace, T., Badger, T., & Sikorskii, A. (2021). Reflexology and meditative practices for symptom management among people with cancer: Results from a sequential multiple assignment randomized trial. Research in Nursing & Health, 44(5), 796–810. https://doi.org/10.1002/nur.22169
Xu, J., Li, H., Sze, D. M., Chan, V. W. S., & Yang, A. W. H. (2025). Effectiveness of qigong and Tai Chi for quality of life in patients with cancer: An umbrella review and meta-analysis. BMC Complementary Medicine and Therapies, 25(1), 141. https://doi.org/10.1186/s12906-025-04875-1
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.
Kampus keperawatan unsoed 
Published By Jurusan Keperawatan FIKES UNSOED
bionursing@unsoed.ac.id
