Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors

PURPOSE

Comorbid insomnia and cancer-related cognitive impairment (CRCI) are experienced by up to 26% of individuals diagnosed with cancer. This study examined the efficacy and durability of cognitive behavioral therapy for insomnia (CBT-I) on perceived CRCI in cancer survivors.

METHODS

Atlantic Canadian cancer survivors with insomnia and CRCI were randomly assigned to receive seven weekly virtual CBT-I sessions (n = 63) or placed in a waitlist control group (n = 69) to receive treatment after the waiting period. Participants completed assessments at baseline, 1 month (mid-treatment), and 2 months (post-treatment). Age- and education-adjusted mixed-effects models using intention-to-treat principles assessed change at post-treatment. Data from both groups were then pooled to assess the durability of effects at 3 and 6 months. A mediation analysis examined whether change in insomnia symptoms mediated the effect of CBT-I on cognitive outcomes.

RESULTS

The mean age of the sample was 60 years, 77% were women, and breast cancer was the most common diagnosis (41%). The treatment group reported an 11.35-point reduction in insomnia severity, compared with a 2.67-point reduction in the waitlist control group (P < .001). The treatment group had a greater overall improvement than the waitlist control on perceived cognitive impairment (P < .001; d = 0.75), cognitive abilities (P < .001; d = 0.92), and impact on quality of life (P < .001; d = 1.01). These improvements were maintained at follow-up. Change in insomnia symptoms fully mediated the effect of CBT-I on subjective cognitive outcomes.

CONCLUSION

Treating insomnia with CBT-I produces clinically meaningful and durable improvements in CRCI. There is an urgent need increase access to evidence-based treatment for insomnia in cancer centers and the community.

A Cross Sectional Survey of Factors Related to Cannabis Use as a Sleep Aid Among Canadian Cancer Survivors

OBJECTIVES

Poor sleep is a common side effect of cancer. Cannabis is increasingly used to manage cancer treatment-related symptoms, including sleep. This study investigated factors related to cannabis use for sleep among Canadian cancer survivors.

METHOD

Adult Canadian cancer survivors (N = 940) were recruited via the Angus Reid Institute and completed an online, cross-sectional survey. Univariate and multiple binomial logistic regression models identified factors associated with cannabis use for sleep.

RESULTS

Of the participants (Mage = 64.5 yrs; Women = 51.1%; White = 92.9%), 25.1% (n = 236) currently use cannabis for sleep. Participants were at greater odds of using cannabis for sleep if they identified as a gender other than man or woman (AOR = 11.132), were diagnosed with multiple medical conditions (2:AOR = 1.988; 3+:AOR = 1.902), two psychological conditions (AOR = 2.171), multiple sleep disorders (AOR = 2.338), insomnia (AOR = 1.942), bone (AOR = 6.535), gastrointestinal (AOR = 4.307), genitourinary (AOR = 2.586), hematological (AOR = 4.739), or an unlisted cancer (AOR = 3.470), received hormone therapy only (AOR = 3.054), drink heavily (AOR = 2.748), or had mild insomnia (AOR = 1.828). Older participants (AOR=.972) and those with sleep apnea were less likely to use cannabis for sleep (AOR=.560).

CONCLUSION

Given its prevalence, research is needed to understand how factors associated with cannabis use as a sleep aid among Canadian cancer survivors may influence its use and effectiveness and whether these factors are barriers to accessing evidence-based treatments.

Establishing the Top 10 Research Priorities for Adolescent and Young Adult (AYA) Cancer in Canada: A Protocol for a James Lind Alliance Priority Setting Partnership

Adolescents and young adults (AYAs; 15-39 years) diagnosed with cancer have unique medical and psychosocial needs. These needs could be better addressed through research that is focused on the topics that matter most to them. However, there is currently no patient-oriented research agenda for AYA cancer in Canada. This manuscript describes the early development and project protocol for a priority-setting partnership (PSP) for establishing the top 10 research priorities for AYA cancer in Canada. This project follows the PSP methodology outlined by the James Lind Alliance (JLA) to engage patients, caregivers, and clinicians in research prioritization. The steps of a JLA PSP include establishing a steering group and project partners, gathering uncertainties, data processing and verifying uncertainties, interim priority setting, and a final priority setting workshop. The AYA cancer PSP will result in a top 10 list of research priorities identified by Canadian AYA patients, caregivers, and clinicians that will be published and shared broadly with the research community. The first steering group meeting was held in April 2023, and the project is ongoing. The establishment of a patient-oriented research agenda for AYA cancer will catalyze a long-term and impactful research focus and ultimately improve outcomes for AYA patients with cancer in Canada.

Management of Fatigue in Adult Survivors of Cancer: ASCO-Society for Integrative Oncology Guideline Update

PURPOSE

To update the ASCO guideline on the management of cancer-related fatigue (CRF) in adult survivors of cancer.

METHODS

A multidisciplinary panel of medical oncology, geriatric oncology, internal medicine, psychology, psychiatry, exercise oncology, integrative medicine, behavioral oncology, nursing, and advocacy experts was convened. Guideline development involved a systematic literature review of randomized controlled trials (RCTs) published in 2013-2023.

RESULTS

The evidence base consisted of 113 RCTs. Exercise, cognitive behavioral therapy (CBT), and mindfulness-based programs led to improvements in CRF both during and after the completion of cancer treatment. Tai chi, qigong, and American ginseng showed benefits during treatment, whereas yoga, acupressure, and moxibustion helped to manage CRF after completion of treatment. Use of other dietary supplements did not improve CRF during or after cancer treatment. In patients at the end of life, CBT and corticosteroids showed benefits. Certainty and quality of evidence were low to moderate for CRF management interventions.

RECOMMENDATIONS

Clinicians should recommend exercise, CBT, mindfulness-based programs, and tai chi or qigong to reduce the severity of fatigue during cancer treatment. Psychoeducation and American ginseng may be recommended in adults undergoing cancer treatment. For survivors after completion of treatment, clinicians should recommend exercise, CBT, and mindfulness-based programs; in particular, CBT and mindfulness-based programs have shown efficacy for managing moderate to severe fatigue after treatment. Yoga, acupressure, and moxibustion may also be recommended. Patients at the end of life may be offered CBT and corticosteroids. Clinicians should not recommend L-carnitine, antidepressants, wakefulness agents, or routinely recommend psychostimulants to manage symptoms of CRF. There is insufficient evidence to make recommendations for or against other psychosocial, integrative, or pharmacological interventions for the management of fatigue.Additional information is available at www.asco.org/survivorship-guidelines.

An Evaluation of Racial and Ethnic Representation in Research Conducted with Young Adults Diagnosed with Cancer: Challenges and Considerations for Building More Equitable and Inclusive Research Practices

The psychosocial outcomes of adolescents and young adults (AYAs) diagnosed with cancer are poorer compared to their peers without cancer. However, AYAs with cancer from diverse racial and ethnic groups have been under-represented in research, which contributes to an incomplete understanding of the psychosocial outcomes of all AYAs with cancer. This paper evaluated the racial and ethnic representation in research on AYAs diagnosed with cancer using observational, cross-sectional data from the large Young Adults with Cancer in Their Prime (YACPRIME) study. The purpose was to better understand the psychosocial outcomes for those from diverse racial and ethnic groups. A total of 622 participants with a mean age of 34.15 years completed an online survey, including measures of post-traumatic growth, quality of life, psychological distress, and social support. Of this sample, 2% (n = 13) of the participants self-identified as Indigenous, 3% (n = 21) as Asian, 3% (n = 20) as "other," 4% (n = 25) as multi-racial, and 87% (n = 543) as White. A one-way ANOVA indicated a statistically significant difference between racial and ethnic groups in relation to spiritual change, a subscale of post-traumatic growth, F(4,548) = 6.02, p < 0.001. Post hoc analyses showed that those under the "other" category endorsed greater levels of spiritual change than those who identified as multi-racial (p < 0.001, 95% CI = [2.49,7.09]) and those who identified as White (p < 0.001, 95% CI = [1.60,5.04]). Similarly, participants that identified as Indigenous endorsed greater levels of spiritual change than those that identified as White (p = 0.03, 95% CI = [1.16,4.08]) and those that identified as multi-racial (p = 0.005, 95% CI = [1.10,6.07]). We provided an extensive discussion on the challenges and limitations of interpreting these findings, given the unequal and small sample sizes across groups. We concluded by outlining key recommendations for researchers to move towards greater equity, inclusivity, and culturally responsiveness in future work.

Early change in fatigue, insomnia, and cognitive impairment and symptom severity 3 years post-treatment in breast cancer survivors

PURPOSE

Breast cancer is the most common form of cancer among Canadian women. Survivorship challenges include fatigue, sleep disturbance, and cognitive impairment. This study examined (1) symptom trajectory from diagnosis to 3 years; (2) whether symptom change in the first 4 months was associated with prolonged difficulties after 3 years; and (3) which factors were associated with deterioration in symptoms during the first 4 months.

METHODS

This prospective observational cohort study examined 53 women (Mage = 58.6, 96.2% White, 67.9% stage I) with newly diagnosed breast cancer over 3 years. Women completed assessments before starting treatment, 4 months, and 3 years after diagnosis. Three-way repeated-measures ANOVAs evaluated symptom trajectories. A repeated-measures mediation analysis was performed to determine if change from pre-treatment to 4 months accounted for change from pre-treatment to 3 years. A series of between-subjects ANOVAs were used to determine what variables significantly differed by deterioration status.

RESULTS

Perceived cognitive impairment and fatigue increased linearly from diagnosis to 3 years. Change in fatigue in the first 4 months fully accounted for its change over 3 years. Insomnia severity and sleep quality deteriorated from diagnosis to 4 months, but returned to pre-treatment levels at 3 years. Those whose fatigue and cognitive ability deteriorated during the first 4 months were younger.

CONCLUSION

Efforts to identify those who are at risk of experiencing fatigue, sleep disturbance, and cognitive impairment; monitor patients early after receiving a diagnosis; and provide targeted interventions may prevent long-term deterioration and improve well-being.

Connectedness to the young adult cancer community and post-traumatic growth: A young adults with cancer in their prime study

OBJECTIVE

For young adults (YAs) with cancer, connecting with peer cancer survivors can provide a unique sense of community and may enhance post-traumatic growth (PTG). This study examined the relationship between connectedness to the YA cancer community and PTG among YAs, independent of overall social support.

METHODS

Data were obtained from the young adults with cancer in their prime study, a cross-Canada survey of YA cancer survivors. Participants were stratified by level of social support into two groups (low/high). Multivariable logistic regression was used to examine the association between PTG and connectedness to the YA community adjusting for respondent characteristics, and the interaction between support and connectedness.

RESULTS

Of 444 respondents, mean age was 34.2 (SD = 6.0), time-since-diagnosis was 4.8 years (SD = 5.4), and 87% were female. Over two-thirds of respondents (71%) reported feeling connected to the YA community. Level of connectedness to the YA community did not differ by social support group, and interaction between social support and connectedness to the YA community was not significant. In the adjusted regression, connectedness to the YA community (aOR = 2.29, 95% CI: 1.10-4.91), high social support (aOR = 2.98, 95% CI: 1.36-6.74), greater time-since-diagnosis (aOR = 1.09, 95% CI: 1.04-1.15) and female sex (aOR = 2.21, 95% CI: 1.23-4.04) were associated with greater odds of moderate-to-high PTG.

CONCLUSIONS

Feeling connected to a community of YA cancer peers was associated with moderate-to-high PTG among YAs, independent of overall perceived social support. Future efforts should increase access to YA cancer communities and foster a sense of connectedness among YAs with cancer.

Reasons for why Medical Students Prefer Specific Sleep Management Strategies

OBJECTIVES

Insomnia symptoms are common among medical students. This study explored the perspectives of medical students about which sleep management strategies to use.

METHODS

Medical students responded to an online survey on their thoughts about the use of various sleep management strategies.

RESULTS

Of the 828 respondents, 568 (69%) provided responses to questions about the most preferred strategies and 450 (54%) provided responses about their least preferred strategies. About 48.5% felt their insomnia symptoms were too mild to see a clinician and 23.9% did not think their symptoms warranted sleep medication. Over 40% of students could not avoid work before sleep, have consistent sleep/wake times, or engage in regular exercise because of their busy and inconsistent schedules. Approximately 40-60% could not improve their sleep environment (e.g. better heating and bed) because of the associated costs. Over 80% reported an inability to change their pre-sleep habits (e.g. using electronics close to bedtime, using bed for activities other than sleep or sex). Half of the students disliked relaxation techniques or felt they would not help. Around 30-50% did not believe that changing caffeine and/or alcohol intake would affect their sleep.

CONCLUSIONS

Medical students may benefit from additional sleep education. Clinicians may need to discuss which strategies individual students prefer and modify their recommendations accordingly.

Perceived Executive Functioning Deficits After Diagnosis in Women with Non-Metastatic Breast Cancer Prior to Adjuvant Therapies

BACKGROUND

Perceived deficits in executive functioning are among the many difficulties that women diagnosed with breast cancer experience. This study assessed the presence of perceived deficits in executive functioning among women with breast cancer prior to systemic treatment and radiation and associations between perceived deficits in executive function and comorbid fatigue, sleep, and mood disturbance.

METHOD

Participants were recruited following their breast cancer diagnosis and assessed using the Behavior Rating Inventory of Executive Function for Adults (BRIEF-A), subjective and objective measures of sleep duration and efficiency, and self-report measures of insomnia severity, sleep quality, fatigue, and mood disturbance. Hierarchical regression was used to examine associations between symptoms, adjusting for age and education.

RESULTS

The final sample included 92 women with a mean age of 60.7 years and 13.5 years of education. Thirteen percent of participants reported global executive dysfunction. After partitioning out variability from other independent variables, fatigue (p = < .001), perceived sleep quality (p = .030), and symptoms of insomnia (p = .008) accounted for 13.3%, 5.7%, and 8.5% of unique variance in perceived executive functioning, respectively. Emotional fatigue was most strongly associated with perceived deficits in executive functioning. Neither subjective or objective sleep duration or efficiency was associated with perceived deficits in executive functioning.

CONCLUSION

Fatigue, particularly emotional fatigue, insomnia, and poor sleep quality had the strongest associations with perceived deficits in executive functioning. Sleep interventions and fatigue management strategies may prove useful for women who seek to improve their perceived executive functioning.

Describing and Exploring Coping Strategies among Those Diagnosed with Cancer as an Adolescent or Young Adult: A YACPRIME Study

A greater understanding of how young people cope with a cancer diagnosis is needed in order to inform age-appropriate supportive care. This paper describes the coping strategies used and explores relationships between coping strategies and personal, medical, and psychological variables among young adults (YAs) diagnosed with cancer. YAs (n = 547, mean age = 34.05 ± 6.00 years) completed an online survey, including the Brief COPE and measures of psychological functioning. Descriptive statistics and bivariate correlations were computed. Acceptance, self-distraction, positive reframing, and planning were the most used coping strategies by this sample. There were small (r = -0.09) to large (r = 0.51) significant relationships between personal, medical, and psychological variables and selected coping strategies. Coping with a cancer diagnosis early in life remains poorly understood. Identifying additional correlates and exploring inter- and intrapersonal variation in coping strategy use is required.

Rural-urban differences in distress, quality of life, and social support among Canadian young adult cancer survivors: A Young Adults with Cancer in Their Prime (YACPRIME) study

PURPOSE

Geographic location plays a significant role in the health and wellbeing of those with cancer. This project explored the impact of rurality and social support on distress and quality of life in young adults (YAs) with cancer in Canada.

METHODS

The current research analyzed data from the Young Adults with Cancer in Their Prime (YACPRIME) study. Participants completed measures of emotional distress (10-item Kessler Psychological Distress Scale), quality of life (12-item Short-form Health Survey), and social support (Medical Outcomes Study-Social Support Survey). Rural and urban-dwelling survivors were compared using MANOVAs. Bivariate analyses were conducted to explore associations between distress and social support.

FINDINGS

Of the sample (N = 379), 26% identified their location as rural. Rural YA cancer survivors reported higher distress and worse physical health-related quality of life (HRQOL) than survivors from urban areas but similar levels of mental-health-related quality of life. Social support appeared to have a marginally greater effect on psychosocial outcomes for urban participants. All types of social support were associated with lower levels of distress. However, different types of social support were associated more strongly with distress depending on a participant's geography.

CONCLUSIONS

Rural-dwelling YA cancer survivors experience significantly more distress and poorer physical HRQOL than urban-dwelling survivors. Different needs and preferences for social support may influence the psychological health of rural cancer survivors. Additional research is needed to determine how best to understand and address distress in rural YAs with cancer.

Androgen deprivation therapy and radiation for prostate cancer-cognitive impairment, sleep, symptom burden: a prospective study

OBJECTIVES

This paper (1) sought to compare sleep, mood and physical symptom profiles of men with prostate cancer (PCa) who experienced subjective and objective cancer-related cognitive impairment (CRCI) during the first year of treatment and (2) examine if fluctuations in mood and physical symptoms are associated with change in subjective or objective CRCI.

METHODS

This prospective observational cohort study examined 24 new patients with PCa receiving androgen deprivation therapy (ADT) and radiation therapy (RT) during the first 12 months of treatment. Participants completed subjective and objective assessments of cognition, sleep continuity and self-report measures of insomnia, fatigue, depression and anxiety. Independent sample t-tests, correlations and hierarchical regressions were used to compare groups, explore associations, and assess change over time. Effects are reported as corrected Cohen's d (dc).

RESULTS

Men with objective CRCI reported worse subjective time asleep (dc=0.47) and more depression (dc=0.55). Men with subjective CRCI reported worse insomnia (dc=0.99), hot flashes (dc=0.76), sleep quality (dc=0.54), subjective total sleep time (dc=0.41), wake after sleep onset (dc=0.71), sleep efficiency (dc=0.49), fatigue (dc=0.67) and objectively estimated sleep latency (dc=0.72) than men without subjective CRCI. Declines in perceived cognition was associated with higher anxiety (p=0.05), fatigue (p≤0.01) and symptoms of insomnia (p=0.01). Finally, subjective time awake during the night (p=0.03) and fatigue (p=0.02) were associated with subjective cognitive decline, controlling for objective change.

CONCLUSIONS

Subjective concerns of CRCI appear more critical to patient experience than objective measurements in men with PCa who have received RT and ADT. Interventions to improve sleep may result in an improved perception of cognition.

A cross-sectional survey of the prevalence and patterns of using cannabis as a sleep aid in Canadian cancer survivors

PURPOSE

Poor sleep is one of the most common side effects of cancer. It can persist for years beyond treatment and negatively impact quality of life and health. Cannabis is increasingly used to manage cancer treatment-related symptoms, including sleep. This study investigated the use and perceived effects of cannabis as a sleep aid in Canadian cancer survivors.

METHODS

Adult Canadian cancer survivors (N = 1464) were recruited via the Angus Reid Institute and completed an online, cross-sectional survey including the Insomnia Severity Index and questions about cannabis use for sleep. Standard descriptive statistics, such as means, standard deviations, and ranges were produced for measured variables to assess the ways cancer survivors use cannabis for sleep. Frequencies were tabulated for categorical and ordinal variables.

RESULTS

On average, participants (Mage = 61.1 years; Women = 50%: Men = 48%) received their cancer diagnosis 12.5 years prior. Of participants, 23.5% (n = 344) currently use cannabis as a sleep aid, with reported benefits including relaxation, reduced time to fall asleep, fewer nocturnal awakenings and improved sleep quality. Two thirds (68.3%, n = 235) only began using cannabis for sleep after their cancer diagnosis. Over a third of participants (36.3%, n = 125) use cannabis as a sleep aid every day. Among the 344, the most common other reasons for using cannabis were pain (31.4%, n = 108), recreational use (24.4%, n = 84), and anxiety (12.5%, n = 43).

CONCLUSIONS

Given the prevalence and potential impact, research is needed to examine the actual efficacy of cannabis as a sleep aid.

IMPLICATIONS FOR CANCER SURVIVORS

It is important that cancer survivors have information on methods to help their sleep to avoid impairments to quality of life and health.

Comparing sleep measures in cancer survivors: Self-reported sleep diary versus objective wearable sleep tracker

Purpose

Cancer survivors are increasingly using wearable fitness trackers, but it's unclear if they match traditional self-reported sleep diaries. We aimed to compare sleep data from Fitbit and the Consensus Sleep Diary (CSD) in this group.

Methods

We analyzed data from two randomized clinical trials, using both CSD and Fitbit to collect sleep outcomes: total sleep time (TST), wake time after sleep onset (WASO), number of awakenings (NWAK), time in bed (TIB) and sleep efficiency (SE). Insomnia severity was measured by Insomnia Severity Index (ISI). We used the Wilcoxon Singed Ranks Test, Spearman's rank correlation coefficients, and the Mann-Whitney Test to compare sleep outcomes and assess their ability to distinguish insomnia severity levels between CSD and Fitbit data.

Results

Among 62 participants, compared to CSD, Fitbit recorded longer TST by an average of 14.6 (SD = 84.9) minutes, longer WASO by an average of 28.7 (SD = 40.5) minutes, more NWAK by an average of 16.7 (SD = 6.6) times per night, and higher SE by an average of 7.1% (SD = 14.4); but shorter TIB by an average of 24.4 (SD = 71.5) minutes. All the differences were statistically significant (all p < 0.05), except for TST (p = 0.38). Moderate correlations were found for TST (r = 0.41, p = 0.001) and TIB (r = 0.44, p < 0.001). Compared to no/mild insomnia group, participants with clinical insomnia reported more NWAK (p = 0.009) and lower SE (p = 0.029) as measured by CSD, but Fitbit outcomes didn't.

Conclusions

TST was the only similar outcome between Fitbit and CSD. Our study highlights the advantages, disadvantages, and clinical utilization of sleep trackers in oncology.

Feasibility and Acceptability of a Virtual "Coping with Brain Fog" Intervention for Improving Cognitive Functioning in Young Adults with Cancer

Purpose: Cancer-related cognitive deficits (CRCDs) are common among young adults (YAs) (ages: 18-39) with cancer and can be debilitating. We aimed to determine the feasibility and acceptability of a virtual Coping with Brain Fog intervention among YAs with cancer. Our secondary aims were to explore the intervention's effect on cognitive functioning and psychological distress. Methods: This prospective feasibility study involved eight weekly, 90-minute virtual group sessions. Sessions focused on psychoeducation on CRCD, memory skills, task management, and psychological well-being. The primary outcomes were feasibility and acceptability of the intervention evaluated through attendance (>60% not missing >2 consecutive sessions) and satisfaction (Client Satisfaction Questionnaire [CSQ] score >20). Secondary outcomes included the following: cognitive functioning (Functional Assessment of Cancer Therapy-Cognitive Function [FACT-Cog] Scale) and symptoms of distress (Patient-Reported Outcomes Measurement Information System [PROMIS] Short Form-Anxiety/Depression/Fatigue) and participants' experiences using semistructured interviews. Paired t-tests and summative content analysis were used for quantitative and qualitative data analyses. Results: Twelve participants (five male, mean age = 33 years) were enrolled. All but one participant met feasibility criteria of not missing >2 consecutive sessions (11/12 = 92%). The mean CSQ score was 28.1 (standard deviation 2.5). Significant improvement in cognitive function as measured by FACT-Cog Scale was observed postintervention (p < 0.05). Ten participants adopted strategies from the program to combat CRCD, and eight reported CRCD symptom improvement. Conclusion: A virtual Coping with Brain Fog intervention is feasible and acceptable for the symptoms of CRCD among YAs with cancer. The exploratory data indicate subjective improvement in cognitive function, and will inform the design and implementation of a future clinical trial. ClinicalTrials.gov Registration: NCT05115422.

Understanding sleep quality in a national cohort of young adult cancer survivors: Results from the YACPRIME study

PURPOSE

A cancer diagnosis in young adulthood can negatively impact sleep quality. The present study describes sleep issues in young adults (YAs) and analyzes potential demographic and clinical characteristics related to sleep quality.

METHODS

Canadian YAs (n = 359) diagnosed with cancer between ages 15-39 participated in the study. Pittsburgh Sleep Quality Index (PSQI) items were examined to identify specific sleep issues that occurred 3+ times per week. Logistic regression was used to examine demographic, clinical, and symptom-related variables associated with poor sleep quality (defined as a PSQI global score >8) and sleep medication use.

RESULTS

Participants were predominantly female (87.5%) with an average age of 32 years. Of the sample, 52% had poor sleep quality, 55.5% took >30 min to fall asleep, 32.9% slept <7 h, and 54.6% reported a habitual sleep efficiency of <85%. YAs with poor sleep quality were 5.7 times more likely to report severe distress (p=<.001), as well as 1.8 times more likely to report poorer mental (p = .03) and physical functioning (p = .05). Nearly half (44%) of YAs used sleep medication to help them sleep. YAs who reported severe psychological distress were 2.4 times more likely to use sleeping medication (p = .01), whereas those with a household income ≥$100,000/year were half as likely to use medication to help with sleep (p = .04).

CONCLUSION

Psychological distress is associated with worse sleep quality and sleep medication use in YA cancer survivors. Sleep quality may be a possible target for future research and intervention to promote long-term function and recovery.

An Investigation of Social Status among Adolescents and Young Adults Who Have Been Diagnosed with Cancer in Canada

BACKGROUND

Aims were to: (1) compare social status among AYAs diagnosed with cancer to a community population; (2) describe AYAs' change in employment/education status; and (3) examine predictors of social status.

METHOD

Social status (i.e., education, employment, relationship status, and living arrangement) was captured from young adults diagnosed with cancer recruited via social media through a community-based organization from across Canada and randomly matched to a community sample by sex, age, province of residence, total household income and race/ethnicity at a ratio of 1:3.

RESULTS

AYAs with cancer (N = 622) were an average of 4.45 (SD = 5.42) years from the completion of treatment and were less likely to be employed (χ² = 96.35, p < 0.001) and more likely to be living at home with parents (χ² = 17.00, p < 0.001). There were no differences in education or relationship status. Overall, 41% and 45% of AYAs reported quitting school or work, respectively. Non-metastatic disease (AOR 3.23, 95% CI 1.08-9.62), and better physical (AOR 1.07 95% CI 1.04-1.10) and mental quality of life (QOL)(AOR 1.06 95% CI 1.03-1.09), were associated with employment. Worse mental QOL (AOR 1.04 95% CI 1.01-1.07), less post-traumatic growth (AOR 1.01 95% CI 1.00-1.03), and social support (AOR 0.27, 95% CI 0.18-0.41) were associated with being single. Non-White race (AOR 3.19 95% CI 1.02-9.97) and less post-traumatic growth (AOR 0.97 95% CI 0.95-0.99) were associated with living with parents.

CONCLUSIONS

AYAs diagnosed with cancer experience differences in attainment of employment and independent living compared to a community sample. These challenges may have implications for physical and mental QOL.

Experiences of adolescent and young adult cancer survivors during the COVID-19 pandemic

PURPOSE

This study aimed to evaluate the impact of the COVID-19 pandemic on adolescent and young adult (AYA) cancer survivors.

METHODS

We conducted a cross-sectional survey of AYAs aged 18-49 with cancer in Canada between January and February 2021. Data from survivors, defined as AYAs more than one year off cancer treatment, were analysed. Multiple logistic regression was used to identify factors associated with psychological distress, loneliness and insomnia.

RESULTS

The analysis included 384 survivors. Moderate-to-severe psychological distress was reported by 257 (68.9%) survivors and was associated with an income ≥ $60,000 (adjusted odds ratio [AOR] 2.15, 95% CI 1.11-4.17) and the presence of a pre-existing chronic physical health condition (AOR 2.05, 95% CI 1.18-3.56). Loneliness was reported by 204 (54.0%) survivors and was associated with being unemployed (AOR 2.26 95%CI 1.18-4.31), pandemic causing finances to be worse (AOR 1.82, 95%CI 1.08-3.06) and the presence of a pre-pandemic mental health condition (AOR 1.88, 95% CI 1.03-3.42). Clinical insomnia was reported by 74 (19.5%) survivors and was associated with employment status as a student (AOR 3.00, 95% CI 1.08-8.29) or unemployed (AOR 3.97, 95% CI 1.46-10.83), earning $60,000 or more in the year 2020 (AOR 4.36, 95% CI 1.43-13.32), having haematologic cancer (AOR 2.21, 95% CI 1.05-4.70) and being single (AOR 2.52, 95% CI 1.08-5.91). Pandemic negatively affected employment, finances, physical activity, cancer care and substance use for 73.9%, 66.5%, 32.5%, 21.8% and 19.2% of survivors, respectively. Worries about finances, contracting COVID-19, cancer treatment increasing the risk of COVID-19 infection, and having poor health outcomes from contracting COVID-19 were reported by 46.0%, 45.6%, 55.0% and 47.3% of survivors, respectively.

CONCLUSIONS

The COVID-19 pandemic has had a significant impact on AYA cancer survivors, and these individuals report high levels of psychological distress, insomnia and loneliness.

IMPLICATIONS FOR CANCER SURVIVORS

Cancer survivors are at risk for worsening mental and physical health outcomes during the COVID-19 pandemic. Targeted interventions and support programs are urgently needed to support the mental health of AYA cancer survivors and optimize their health outcomes.

Addressing cancer-related fatigue through sleep: A secondary analysis of a randomized trial comparing acupuncture and cognitive behavioral therapy for insomnia

Background

Fatigue is a troublesome symptom in cancer survivors that often results from disrupted sleep. We sought to assess whether two insomnia-focused non-pharmacological interventions are also effective for improving fatigue.

Methods

We analyzed data from a randomized clinical trial comparing cognitive behavioral therapy for insomnia (CBT-I) versus acupuncture for insomnia among cancer survivors. Participants were 109 patients who reported insomnia and moderate or worse fatigue. Interventions were delivered over eight weeks. Fatigue was evaluated at baseline, week 8, and week 20 using the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). We used both mediation analysis and t-tests to explore the extent to which fatigue reduction was attributable to insomnia response.

Results

Compared to baseline, both CBT-I and acupuncture produced significant reductions in total MFSI-SF scores at week 8 (-17.1 points; 95% confidence interval [CI]: -21.1 to -13.1, and -13.2 points; 95% CI: -17.2 to -9.2, respectively, all p<0.001) and week 20 (-14.6 points; 95% CI: -18.6 to -10.6, and -14.2 points; 95% CI: -18.1 to -10.3. respectively, all p<0.001), with no significant between-group differences. MFSI-SF total scores at week 8 were significantly associated with sleep improvements in both CBT-I and acupuncture groups (p<0.001 and p=0.011, respectively). Insomnia responders demonstrated significantly greater improvements in mean MFSI-SF total scores compared with non-responders in the CBT-I group (p=0.016) but not in the acupuncture group.

Conclusion

CBT-I and acupuncture produced similar, clinically meaningful, and durable fatigue reductions in cancer survivors with insomnia, primarily through improvements in sleep. Acupuncture may also reduce fatigue through additional pathways.

The financial impact of cancer on Canadian young adults

PURPOSE

To explore the financial impact of cancer in young adults (YAs) compared to matched non-cancer peers.

METHODS

Five hundred seventy-five YAs from the Young Adults with Cancer in their Prime (YACPRIME) study reported on out-of-pocket cancer costs and missed work. YA cancer survivors were compared to matched peers without cancer on key financial indices based on current age (< 35 vs. 35 + years) and time since diagnosis (< 5 vs. 5 + years). Descriptive statistics, Chi-square tests, and prevalence ratios (PR) were used to compare groups on financial variables.

RESULTS

Almost 60% of YA survivors spent at least $100/month on cancer-related expenses, and 49% missed at least one year of work. YA survivors were more likely to have outstanding credit card ((< 35 (PR = 1.37, p = 0.001); 35 + (PR = 1.33, p = 0.001)) and line of credit (< 35 (PR = 1.42, p = 0.008); 35 + (PR = 1.27, p = 0.016)) balances. Home ownership was higher among non-cancer peers ((< 35: PR = 1.42, p < 0.001); 35 + (PR = 1.69, p < 0.001); < 5 years (PR = 1.39, p < 0.001); 5 + years (PR = 1.41, p = 0.005)). YA survivors were more likely to not own assets ((< 5 years (PR = 2.25, p < 0.001); 5 + years (PR = 2.25, p = 0.004)). Those diagnosed within 5 years had higher rates of payday loans (PR = 3.91, p = 0.021).

CONCLUSION

While exploratory, results suggest that YAs are disadvantaged compared to their peers in type and value of assets owned and debts carried.

IMPLICATIONS FOR CANCER SURVIVORS

Survivorship care plans for YA survivors should include resources to manage the financial impacts of cancer.

A comparison of the sociodemographic, medical, and psychosocial characteristics of adolescents and young adults diagnosed with cancer recruited in-person and online: A Canadian cross-sectional survey

Introduction

Adolescents and young adults diagnosed with cancer (AYAs) are under-represented in research. The Internet and social media could increase the reach of recruitment efforts but may impact sample characteristics. This study evaluated the characteristics of AYAs recruited in-person at an urban hospital versus the Internet in terms of their sociodemographic and medical characteristics, and psychosocial wellbeing, and offers recommendation for increasing the inclusivity and representativeness of research samples.

Methods

Participant data from a cross-sectional survey of AYAs in Canada were evaluated. In-person hospital recruitment used a registry to identify patients attending ambulatory clinics. Internet recruitment included notices on hospital, team members', and community partners' social media channels, and email newsletters. Independent sample t-tests and Chi-squared tests were used to identify differences in participant sociodemographic, medical, and psychosocial characteristics based on recruitment source.

Results

Of 436 participants, 217 (49.8%) were recruited in-person and 219 (50.2%) online. Online participants were more likely: to be white (p < .001), women (p < .001), and Canadian-born (p < .001); to speak English at home (p < .001), live alone (p = .001) and live in rural settings (p = .014); and to be farther from diagnosis (p = .023), diagnosed with breast cancer (p < .001), and cancer free (p < .001) compared to the hospital sample. Online participants also reported higher anxiety, depression, and loneliness (p < .001), and lower social support (p < .001), self-efficacy for coping with cancer (p < .001), and life satisfaction (p = .006).

Conclusions

Online recruitment yielded a more geographically diverse but less sociodemographically diverse sample of AYAs who were farther from diagnosis and had poorer psychosocial wellbeing than in-person recruitment at an urban hospital. Future research efforts should consider partnering with under-represented communities and using targeted and stratified online and in-person recruitment strategies to achieve an inclusive and representative sample of AYAs.

Sleep Management Strategies Among Medical Students At the University of Otago

OBJECTIVES

We aim to investigate factors which might affect the sleep of medical students, and how they currently manage their sleep.

METHODS

An online survey was sent to medical students at the University of Otago.

RESULTS

After adjusting for gender, ethnicity and age, depressive symptoms (Mild: odds ratio (OR) = 6.3; Moderate: OR = 18.1; Severe: OR = 15.6), and sleep hygiene (OR = 1.07) were associated with insomnia symptoms. Commonly endorsed strategies for sleep management by students were undertaking regular exercise (80.1%), having consistent sleep-wake time (71.3%), and limiting caffeine intake (70.3%). Few were willing to see a clinician (23.4%) or take medication (22.3%). Participants with insomnia symptoms were more likely to prefer limiting their alcohol intake (OR = 1.8), limiting daytime naps (OR = 1.5), seeing clinicians (OR = 1.9), and taking sleep medication (OR = 4.0), but less likely to prefer avoiding intense work (OR = .71) or minimizing using electronics (OR = .60) close to bedtime than those without insomnia symptoms. High sleep self-efficacy was associated with lower odds for having insomnia symptoms (OR = .74 (.70, .77)).

CONCLUSIONS

Increased awareness and greater resources are needed to support the sleep health of medical students.

The sleep, cancer and rest (SleepCaRe) trial: Rationale and design of a randomized, controlled trial of cognitive behavioral and bright light therapy for insomnia and fatigue in women with breast cancer receiving chemotherapy

BACKGROUND

Insomnia and fatigue symptoms are common in breast cancer. Active cancer treatment, such as chemotherapy, appears to be particularly disruptive to sleep. Yet, sleep complaints often go unrecognised and under treated within routine cancer care. The abbreviated delivery of cognitive behavioral therapy for Insomnia (CBTI) and bright light therapy (BLT) may offer accessible and cost-effective sleep treatments in women receiving chemotherapy for breast cancer.

METHODS

The Sleep, Cancer and Rest (SleepCaRe) Trial is a 6-month multicentre, randomized, controlled, 2 × 2 factorial, superiority, parallel group trial. Women receiving cytotoxic chemotherapy for breast cancer at tertiary Australian hospitals will be randomly assigned 1:1:1:1 to one of four, non-pharmacological sleep interventions: (a) Sleep Hygiene and Education (SHE); (b) CBTI; (c) BLT; (d) CBT-I + BLT combined and simultaneously delivered. Each sleep intervention is delivered over 6 weeks, and will comprise an introductory session, a mid-point phone call, and regular emails. The primary (insomnia, fatigue) and secondary (health-related quality of life, rest activity rhythms, sleep-related impairment) outcomes will be assessed via online questionnaires at five time-points: baseline (t0, prior to intervention), mid-point intervention (t2, Week 4), post-intervention (t3, Week 7), 3-months (t4, Week 18), and 6-months follow-up (t5, Week 30).

CONCLUSIONS

This study will report novel data concerning the comparative and combined efficacy of CBT-I and BLT during chemotherapy. Findings will contribute to the development of evidence-based early sleep and fatigue intervention during chemotherapy for breast cancer. Clinical trial information Registered with the Australian New Zealand Clinical Trials Registry (http://anzctr.org.au/), Registration Number: ACTRN12620001133921.

Prevalence and factors associated with insomnia symptoms in adolescents and young adults with cancer during the COVID-19 pandemic

OBJECTIVE

The COVID-19 pandemic has been particularly distressing for adolescents and young adults (AYAs) diagnosed with cancer. High levels of distress are associated with sleep disturbances. This study examined the prevalence of insomnia symptoms in AYAs during the COVID-19 pandemic and identified factors related to greater insomnia severity.

DESIGN, SETTING, AND PARTICIPANTS

An online survey was administered to Canadian AYAs (N = 805) diagnosed with cancer between 15 and 39 years from January to February 2021.

MEASUREMENTS

The primary measure was the Insomnia Severity Index (ISI). Univariable and multivariable binomial logistic regression examined demographic, clinical, and psychological factors associated with significant insomnia symptoms (ISI score ≥12).

RESULTS

Three hundred twelve (38.8%) participants reported insomnia symptoms. In the multivariable model, severe psychological distress (ie, depression and anxiety; adjusted odds ratio (AOR) = 28.75, p ≤.001), having a pre-existing mental health condition (AOR = 1.92, p = .03), worsened mental health during the pandemic (AOR = 1.73, p = .02), finished cancer treatment ≥1 year ago (AOR = 1.72, p = .03), and experiencing no changes to schooling during the COVID-19 pandemic (AOR = 2.18, p = .004) were associated with significant insomnia symptoms. Standardized coefficients also indicated that worrying about possible disruptions to cancer care and being a homemaker/caretaker contributed to insomnia symptoms.

CONCLUSIONS

Nearly 40% of AYAs with cancer reported insomnia symptoms during the COVID-19 pandemic. Insomnia was associated with potentially modifiable factors such as psychological distress, highlighting possible targets for intervention.