Body image concerns of young adult cancer survivors: A brief report

BACKGROUND

The purpose of this study was to describe body image among young adult (YA) cancer survivors and examine relationships between body image and personal, medical, and psychosocial variables. Methods: YAs (n = 522; M_age = 34 ± 6 years) completed an online survey and data were analyzed using descriptive statistics, bivariate correlations, and appropriate tests of mean differences. Results: Higher body image concerns were related to less time since diagnosis, lower post-traumatic growth and social support, greater distress, and a higher number of treatments received (rs = .09 to .42; ps < .05). Body image concerns were higher for those currently on treatment (p < .05). Conclusions: Findings suggest greater attention to YAs' body image is necessary. Specifically, longitudinal research and the development of strategies dedicated to reducing body image concerns among YAs are needed.

Fertility Preservation in Young Adults: Prevalence, Correlates, and Relationship with Post-Traumatic Growth

Purpose: This study describes the prevalence of fertility preservation (FP) knowledge, discussions, and engagement in a heterogeneous sample of Canadians diagnosed with cancer in young adulthood and tests the relationship of these variables with later post-traumatic growth (PTG). Methods: Data were taken from the Young Adults with Cancer in their Prime (YACPRIME) study, a national cross-sectional survey of Canadians diagnosed with cancer as young adults. This subanalysis included 463 individuals, ages 20-39 years (mean = 30.28, standard deviation = 4.68, 88% female), diagnosed after 2006. Participants self-reported demographics, responded to questions regarding their experience with FP, and completed the PTG inventory. Results: In total, 81% reported awareness of risk, 52% discussed FP, and 13% pursued FP. PTG was higher for those with knowledge of fertility risk [F (3, 455) = 3.26, p = 0.021], when controlling for sex and on treatment status, but did not differ between those who discussed FP versus not, or made arrangements versus not. Those who reported not engaging in FP because of their own choice [F(3, 402) = 5.98; p = 0.001] or their doctor's recommendation not to delay treatment [F(3, 402) = 3.25; p = 0.022] reported significantly higher PTG, when controlling for sex and on-treatment status. Financial reasons, lack of knowledge about FP, and age were not related to PTG. Conclusions: This study demonstrates that FP discussions and uptake remain low, highlighting the need for continued education and efforts to improve access to intervention. Knowledge of risk, along with making the choice to prioritize treatment over FP, was related to higher PTG, suggesting informed decisions made early in treatment may support positive psychosocial outcomes.

Associations between device use before bed, mood disturbance, and insomnia symptoms in young adults

OBJECTIVES

Young adults (YAs) are vulnerable to insomnia and mood disturbance. YAs also engage in back-lit device use which has been implicated in the development and maintenance of insomnia. This study explored the association between device use, mood disturbance, and insomnia symptoms in YAs.

PARTICIPANTS

Two thousand three hundred and ninety students at a Canadian university, aged 18-35 years.

DESIGN

Cross-sectional online survey MEASUREMENTS: Participants self-reported duration and frequency of back-lit device use before sleep and during the night. The Insomnia Severity Index and the Hospital Anxiety and Depression Scale were used to measure symptoms. Univariate and multivariate logistic regressions explored associations between device use behaviors and insomnia symptoms. A hierarchical regression analysis identified the unique contribution of back-lit device use on insomnia severity adjusting for mood disturbance, age, and sex.

RESULTS

Using a back-lit device for 1-2 hours after lights out (adjusted odds ratio [AOR] = 1.50, p < 0.001), being awakened by a device (AOR = 1.34, p = 0.002), and believing that device use negatively impacts sleep (AOR = 2.27, p < 0.001) were associated with insomnia symptoms. Depression contributed to the greatest unique variance to insomnia (11.8%), followed by anxiety (7.2%). Duration of device use after lights out, being awakened by a device and a negative perception of device use on sleep accounted for an additional 3%.

CONCLUSIONS

Device use contributed to insomnia symptoms over and above mood disturbance, age, and biological sex in YAs. Additional research is needed to determine the direction of effect and inform prevention/intervention programs specific to device use and insomnia symptomology in this population.

Effects of acupuncture versus cognitive behavioral therapy on cognitive function in cancer survivors with insomnia: A secondary analysis of a randomized clinical trial

BACKGROUND

Cancer-related cognitive impairment is a prevalent, disruptive condition potentially exacerbated by sleep disturbances. The current study was performed to evaluate the effects of acupuncture versus cognitive behavioral therapy for insomnia (CBT-I) on objective and subjective cognitive function in cancer survivors with insomnia.

METHODS

Using data from a randomized clinical trial (160 survivors) that compared acupuncture versus CBT-I for insomnia occurring in cancer survivors, the authors analyzed cognitive outcomes and their relationship to insomnia symptoms. Analysis was limited to 99 patients who reported baseline cognitive difficulties. Interventions were delivered over 8 weeks. Objective attention, learning, and memory were evaluated using the Buschke Selective Reminding Test. Subjective cognitive function was assessed using the Brown Attention-Deficit Disorder Scales. Insomnia symptoms were assessed using the Insomnia Severity Index. All outcomes were collected at baseline, week 8, and week 20.

RESULTS

From baseline to week 8, acupuncture produced statistically significant within-group improvements in objective attention (Cohen D, 0.29), learning (Cohen D, 0.31), and memory (Cohen D, 0.33) that persisted to week 20 (all P < .05), whereas CBT-I produced a statistically significant within-group improvement in objective attention from baseline to week 20 (Cohen D, 0.50; P < .05); between-group differences were not statistically significant. Both interventions produced statistically significant within-group improvements in subjective cognitive function at weeks 8 and 20 compared with baseline (all P < .001); between-group differences were not statistically significant. In the acupuncture group, patients with clinically meaningful responses with regard to insomnia symptoms demonstrated a significantly greater improvement in subjective cognitive function compared with those without clinically meaningful insomnia responses (P = .006).

CONCLUSIONS

Among cancer survivors with insomnia, both acupuncture and CBT-I produced significant improvements in objective and subjective cognitive function. However, the effect sizes varied and only survivors in the acupuncture group demonstrated a significant relationship between cognitive and sleep outcomes. These preliminary findings warrant further investigation to guide the personalized management of patients with cancer-related cognitive impairment.

Acupuncture Versus Cognitive Behavioral Therapy for Insomnia in Cancer Survivors: A Randomized Clinical Trial

BACKGROUND

Insomnia is a common and debilitating disorder experienced by cancer survivors. Although cancer survivors express a preference for using nonpharmacological treatment to manage insomnia, the comparative effectiveness between acupuncture and Cognitive Behavioral Therapy for Insomnia (CBT-I) for this disorder is unknown.

METHODS

This randomized trial compared 8 weeks of acupuncture (n = 80) and CBT-I (n = 80) in cancer survivors. Acupuncture involved stimulating specific points on the body with needles. CBT-I included sleep restriction, stimulus control, cognitive restructuring, relaxation training, and education. We measured insomnia severity (primary outcome), pain, fatigue, mood, and quality of life posttreatment (8 weeks) with follow-up until 20 weeks. We used linear mixed-effects models for analyses. All statistical tests were two-sided.

RESULTS

The mean age was 61.5 years and 56.9% were women. CBT-I was more effective than acupuncture posttreatment (P < .001); however, both acupuncture and CBT-I produced clinically meaningful reductions in insomnia severity (acupuncture: -8.31 points, 95% confidence interval = -9.36 to -7.26; CBT-I: -10.91 points, 95% confidence interval = -11.97 to -9.85) and maintained improvements up to 20 weeks. Acupuncture was more effective for pain at the end of treatment; both groups had similar improvements in fatigue, mood, and quality of life and reduced prescription hypnotic medication use. CBT-I was more effective for those who were male (P < .001), white (P = .003), highly educated (P < .001), and had no pain at baseline (P < .001).

CONCLUSIONS

Although both treatments produced meaningful and durable improvements, CBT-I was more effective and should be the first line of therapy. The relative differences in the comparative effectiveness between the two interventions for specific groups should be confirmed in future adequately powered trials to guide more tailored interventions for insomnia.

1031 Exploring the Impact of Cognitive Behavioral Therapy for Insomnia (CBT-I) on Daytime Productivity in Survivors of Breast Cancer

Introduction

Post-treatment insomnia disorder and fatigue symptoms can impair work and daytime productivity in breast cancer survivors. Cognitive Behavioral Therapy for Insomnia (CBT-I) significantly improves insomnia and daytime fatigue. This feasibility study examined whether improving insomnia and fatigue using CBT-I is associated with improved work and activity productivity in breast cancer survivors.

Methods

10 survivors of early stage breast cancer participated in 7 weekly individual CBT-I sessions. The primary outcome was the Work Productivity and Activity Impairment Questionnaire-General Health (WPAIQ-GH) questionnaire. Secondary outcomes were the Insomnia Severity Index (ISI) and the Multidimensional Fatigue Symptom Inventory-Short Form (MFSI-SF). Assessments were conducted at baseline and post-treatment. Paired samples t-tests examined the impact of CBT-I on productivity and fatigue. Linear regression assessed whether change in fatigue was associated with change in productivity.

Results

Participants had a mean age of 50.8 (range 42-63) and the majority were diagnosed with stage II (60%) cancer. There was a significant reduction in fatigue [t(9)= 2.43, p =.04] and activity impairment due to insomnia [t(9)= 3.105, p &lt;.05] following treatment. Insomnia affected 52% of work productivity at baseline with a non-significant decrease to 15% following treatment [t(3)= 2.25 p= .110]. Reductions in fatigue were significantly associated with reductions in activity impairment [F(1,8)= 7.25, p =.03], accounting for 47.5% of the variability.

Conclusion

Treating insomnia with CBT-I significantly improved daytime productivity, activity impairment, and fatigue. Controlled research with larger sample sizes is warranted to confirm these preliminary results.

Support

Nyissa Walsh is a trainee in the Cancer Research Training Program of the Beatrice Hunter Cancer Research Institute (BHCRI). Dr. Sheila Garland is supported by a Scotiabank New Investigator Award from BHCRI.

1036 Does Diary and Actigraphy Measured Sleep Differ Between Good and Poor Sleepers During Breast Cancer Treatment?

Introduction

Women may enter in breast cancer (BCa) treatment with poor sleep, or it may begin during treatment. We assessed how subjective and objective sleep changes during the first year of treatment for women with BCa. Further, we examined whether this differs between previously good and poor sleepers and whether there was agreement between subjective and objective measures of sleep.

Methods

Sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE) were measured among 100 patients with newly diagnosed, non-metastatic BCa using 7 days of diary and actigraphy collected at 4 time points: pre-treatment, 4, 8, and 12 months. Women with a score ≥5 on the Pittsburgh Sleep Quality Index at treatment onset were classified as poor sleepers. A 4 (time: 0-, 4-, 8-, 12-months) by 2 (sleep measure: sleep diary, actigraphy) by 2 (group: good, poor sleepers) mixed model ANOVAs was performed for each sleep parameter.

Results

There was a time by sleep measure by group interaction for TST, [F(3,294)= 3.014, p = .03). Good sleepers reported greater TST on diaries- than actigraphy at pre-treatment and 12 months, whereas there were no differences in poor sleepers. There was a group by time effect for good vs. poor sleepers [F(3,294)= 2.909, p = .035]. Good sleepers experienced decreased TST and SE from pre-treatment through 4-mo, followed by increases. Poor sleepers showed the opposite pattern. Neither group returned to pre-treatment levels. Sleep diaries and actigraphy are concordant over time for TST, but not SOL, WASO, or SE.

Conclusion

Sleep parameters worsen during the first year following onset of BCa and concordance between sleep diaries and actigraphy differ between good or poor sleepers.

Support

Dr. Garland is supported by a Scotiabank New Investigator Award and seed funding from the Beatrice Hunter Cancer Research Institute (BHCRI).

1037 One Year Trajectory of Insomnia and Comorbid Symptoms in Women With Early Stage Breast Cancer

Introduction

Insomnia symptoms are a common problem and are often comorbid with hot flashes, fatigue, anxiety, and depression following a breast cancer diagnosis. The present study examined changes in insomnia severity and comorbid symptoms in the year following diagnosis.

Methods

This study is part of a larger prospective observational cohort study of 100 women with early stage breast cancer. Insomnia symptoms were measured using the Insomnia Severity Index, fatigue was measured using the Multidimensional Fatigue Symptom Inventory-Short Form, anxiety and depression were assessed using the Hospital Anxiety and Depression Scale, and hot flashes were assessed using the Hot Flash Related Daily Interference Scale. Assessments were performed shortly after diagnosis, 4, 8, and 12 months. A series of repeated measures within subjects ANOVAs were performed to assess changes in symptoms over time.

Results

Among 100 women with breast cancer, 45% reported at least mild insomnia symptoms. There were significant quadratic effects of time on insomnia severity, F(3, 297)= 12.776, p ≤ .001, depression (F[3, 297]= 4.409, p = .005), and fatigue (F[3, 297]= 7.995, p ≤ .001). These symptoms initially worsen and then improve throughout the year, but they do not rebound to pre-treatment levels. Interference from hot flashes worsens and endures for longer than other symptoms but does begin to show improvement one year post-diagnosis (F[3, 297]= 12.110, p ≤ .001). The were no time effects for anxiety (F[3, 297] = 1.4, p = .243).

Conclusion

In general, women treated for breast cancer can expect insomnia and comorbid symptoms to worsen then improve, but not recover, during the first year after a breast cancer diagnosis. Early efforts to educate women and manage symptoms could prevent insomnia and other issues from becoming persistent problems.

Support

Dr. Garland is supported by a Scotiabank New Investigator Award and seed funding from the Beatrice Hunter Cancer Research Institute (BHCRI).

1045 Impact Of Pre-treatment Sleep And Menopausal Status On Sleep Quality In The 12 Months Following A Breast Cancer Diagnosis

Introduction

Sleep disturbances are a prevalent and enduring problem in women who have completed treatment for breast cancer. Less is known about whether sleep during and after cancer treatment is influenced by pre-treatment sleep quality and menopausal status. The present study aims to examine the trajectory of sleep quality in the 12 months following a cancer diagnosis and assess whether trajectory is influenced by pre-treatment sleep quality and menopausal status.

Methods

Newly-diagnosed women (N=88) with non-metastatic BCa were recruited before beginning treatment. They completed the Pittsburgh Sleep Quality Index (PSQI) before treatment and 4, 8, and 12 months later. Women with a score ≥5 on the Pittsburgh Sleep Quality Index at treatment onset were classified as poor sleepers. Menopausal status (pre- or post-menopausal) was chart abstracted. A mixed ANOVA assessed the impact of pre-treatment sleep quality and menopausal status on sleep quality trajectory.

Results

The mean age of the sample was 60 years, 70% were classified as poor sleepers, and 72% were post-menopausal. There was a significant linear time by sleep quality interaction, F(1, 83)= 5.79, p =.02. Good sleepers experienced a greater initial worsening of sleep quality than poor sleepers. At 12 months, poor sleepers had returned to baseline levels whereas scores in good sleepers remained higher than baseline. The 3-way time x sleep quality x menopausal status and the 2-way time by menopausal status interactions were not significant.

Conclusion

Baseline sleep quality is a more powerful determinant of sleep trajectory during treatment than menopausal status. Early intervention is necessary to treat existing sleep problems and prevent the development of sleep problems in women with a history of good sleep.

Support

Dr. Garland is supported by a New Investigator Award and seed funding from the Beatrice Hunter Cancer Research Institute (BHCRI).

The INternet ThERapy for deprESsion Trial (INTEREST): protocol for a patient-preference, randomised controlled feasibility trial comparing iACT, iCBT and attention control among individuals with comorbid chronic pain and depression

INTRODUCTION

Approximately one-third of adults with chronic pain also report clinically relevant levels of depression. Internet-delivered psychological therapies such as Cognitive Behavioural Therapy (iCBT) and Acceptance and Commitment Therapy (iACT) have been developed to overcome barriers of access to services and ensure the timely delivery of care. The objective of this trial is to collect data on feasibility, acceptability and range of probable effect sizes for iCBT and iACT interventions tailored towards the treatment of depression and chronic pain using a randomised controlled patient-preference design.

METHODS AND ANALYSIS

Community dwelling adults with chronic non-cancer pain (CNCP) and major depression will be recruited from pain clinics and primary care providers in Newfoundland and Labrador, Canada. The study is a randomised controlled patient-preference trial. Eligible patients will be randomly assigned to a 'preference' or 'no-preference' arm during the first step of randomisation and to intervention or control in the second step of randomisation. Two interventions (ie, iCBT or iACT) will be evaluated relative to attention control. iCBT and iACT involve the completion of 7-weekly online modules augmented with one session of motivational enhancement and weekly therapy sessions. Primary outcomes include (1) feasibility and acceptability parameters and (2) change in symptoms of depression. Secondary outcomes include pain, physical function, emotional function and quality of life. We will recruit 60 participants and examine the range of effect sizes obtained from the trial but will not conduct significance testing as per recommendations for behavioural trial development.

ETHICS AND DISSEMINATION

Ethics was approved by the provincial Health Research Ethics Board. Dissemination of results will be published in a peer-reviewed academic journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT04009135.

Evaluating the experience of rural individuals with prostate and breast cancer participating in research via telehealth

INTRODUCTION

Studies that use objective assessments often only recruit individuals in the geographic region in which the study is being conducted, because the assessments require that the researcher and participant be face to face. This limits the number and variety of individuals who can participate. Telehealth is one approach that could be used to increase sample size and representativeness. The present analysis aims to evaluate the experience of individuals diagnosed with breast or prostate cancer, who participated by telehealth in studies investigating the effects of cancer treatment on sleep and cognition. Specifically, this study aimed to highlight potential benefits of using telehealth and identify ways to improve the process for future studies and assessments.

METHODS

Telephone interviews were conducted with 20 individuals with cancer who participated via telehealth in a larger study investigating the effects of cancer treatment on sleep and cognition; 12 individuals had breast cancer and 8 individuals had prostate cancer. Participants were organized into the four regional health authorities of Newfoundland and Labrador: Eastern, Western, Central, and Grenfell-Labrador. Participants of varying ages and communities were purposively selected. Participants were interviewed about their experience participating in the study via telehealth and invited to offer suggestions for how to improve the process. Interview transcripts were coded using a thematic analysis approach. Demographic information was used to characterize the sample.

RESULTS

Including telehealth as an option in the overall study allowed for a 55% sample size increase for participants with breast cancer, and a 45% sample size increase for participants with prostate cancer. Participants reported an overall positive experience (70% reported the experience as good and/or great), with telehealth allowing for greater convenience, more personable interactions, increased access, and an otherwise unavailable opportunity to help others and themselves. Identified areas for improvement were sound quality, and better access for those who still face barriers of commuting to telehealth locations. Inter-rater reliability yielded a 92% agreement.

CONCLUSIONS

For studies and assessments requiring face-to-face contact, telehealth is clearly a feasible option for improving research representativeness and access for individuals residing in rural areas. Future research should make use of telehealth services, to give a voice to rural individuals who are too often left out.

The Relationship Between Insomnia and Cognitive Impairment in Breast Cancer Survivors

Background

Cancer-related cognitive impairment is an emerging public health burden. Growing research suggests that sleep disturbances contribute to poor cognition. Our study aimed to evaluate the association between insomnia and cognitive impairment in breast cancer survivors.

Methods

We analyzed cross-sectional data from a cohort study of postmenopausal women with stage 0–III hormone receptor-positive breast cancer on aromatase inhibitor therapy. The study was conducted between November 2011 and April 2015 at an academic cancer center (Philadelphia, PA). Insomnia was assessed with the Insomnia Severity Index. Perceived cognitive impairment was assessed with the cognitive subscale of the Breast Cancer Prevention Trial Symptom Checklist. We used linear regression to evaluate the association between insomnia and perceived cognitive impairment.

Results

Among 1072 patients, 556 (51.9%) reported insomnia and 847 (79.0%) were bothered by cognitive symptoms (forgetfulness, difficulty concentrating, distractibility). Greater perceived cognitive impairment was reported by patients with mild insomnia (regression coefficient [β] = 0.35, 95% confidence interval [CI] = 0.23 to 0.46, P < .001), moderate insomnia (β = 0.51, 95% CI = 0.36 to 0.65, P < .001), and severe insomnia (β = 0.94, 95% CI = 0.67 to 1.21, P < .001), compared with those without insomnia. Greater perceived cognitive impairment was also associated with patients younger than 55 years (β = 0.30, 95% CI = 0.15 to 0.45, P < .001), taxane-based chemotherapy (β = 0.11, 95% CI = 0.004 to 0.22, P = .04), anxiety (β = 0.47, 95% CI = 0.30 to 0.64, P < .001), and depression (β = 0.65, 95% CI = 0.35 to 0.94, P < .001).

Conclusions

Among postmenopausal breast cancer survivors receiving aromatase inhibitor therapy, insomnia and cognitive impairment are prevalent and characterized by a graded association, in which severity of perceived cognitive impairment increases as insomnia severity increases. Our findings warrant further research to determine whether addressing sleep is a strategy to improve management of cancer-related cognitive impairment.

Acupuncture versus cognitive behavioral therapy for cognitive impairment in cancer survivors with insomnia: Implications for personalized medicine

11522

Background: Cognitive impairment is a prevalent condition among cancer survivors that lacks effective treatment and can be maintained and exacerbated by poor sleep. This study explored whether treating insomnia with acupuncture or Cognitive Behavioral Therapy for Insomnia (CBT-I) improves subjective and objective cognitive functions in cancer survivors. Methods: We analyzed cognitive outcomes from a pragmatic randomized trial comparing acupuncture versus CBT-I for cancer survivors with insomnia. Analysis was limited to those reporting cognitive impairment at baseline. Acupuncture and CBT-I were delivered over 8 weeks. Perceived cognitive ability was assessed using the Brown Attention-Deficit Disorder Scale (BADDS). Objective cognitive function was evaluated with the Buschke Selective Reminding Test (BSRT). All outcomes were evaluated at baseline, Week 8 (end of intervention), and Week 20 (12 weeks post-intervention). Results: Among 99 cancer survivors, mean age was 60.4 years, 56.6% were women, and 26.3% were non-white. The most common cancer types were breast (31.3%) and prostate (19.2%). Perceived cognitive ability improved in both acupuncture and CBT-I groups at weeks 8 and 20 relative to baseline (all P < 0.001). No significant between-group differences were noted in BADDS total score (p = 0.28), but the CBT-I group demonstrated a better BADDS attention subscale score than the acupuncture group at weeks 8 and 20 (p = 0.031). With regards to objective cognitive functions assessed by BSRT, acupuncture improved attention (p = 0.017), learning (p = 0.040), and memory (p = 0.0020) at Week 8, whereas CBT-I only improved attention at Week 20 (p = 0.0002); between-group differences were not statistically significant. Conclusions: Among cancer survivors with insomnia, both acupuncture and CBT-I improved cognitive impairment relative to baseline, but their relative effects differed: the CBT-I group showed slightly better subjective attention, whereas the acupuncture group may have improved objective memory. Further investigation of these two therapies may lead to effective and personalized interventions for cancer survivors. Clinical trial information: NCT02356575.

Cognitive Behavioral Therapy for Insomnia Reduces Depression in Cancer Survivors

STUDY OBJECTIVES

The current archival analyses examine the direct and indirect effects of cognitive behavioral therapy for insomnia (CBT-I) on depression in cancer survivors.

METHODS

We report on 67 cancer survivors from a 2 × 2 randomized controlled trial of CBT-I and armodafinil for insomnia, after collapsing across the noneffective study medication conditions (armodafinil/placebo) to create CBT-I (yes/no). Depression and insomnia were assessed before, during the 7-week CBT-I intervention, at postintervention, and 3 months later by the Patient Health Questionnaire and the Insomnia Severity Index, respectively.

RESULTS

Mean depression at baseline for all participants was 6.44 (standard error = 0.41, range 0-15). Paired t tests showed that depression improved from baseline to postintervention by 48% (P < .001) in the CBT-I group versus 15% (P = .016) in the non-CBT-I group. Analysis of covariance controlling for baseline found that participants receiving CBT-I had significantly less depression at postintervention (effect size = -0.62; P = .001), compared to those who did not receive CBT-I. These benefits were maintained at the 3-month follow-up. Spearman rank correlations showed that changes in insomnia severity from baseline to postintervention were significantly correlated with concurrent changes in depression (r = .73; P < .001). Path analysis revealed that improvement in depression was mediated by improvement in insomnia severity (P < .001).

CONCLUSIONS

Our findings provide preliminary support that in cancer survivors, CBT-I reduces depression via improvement in insomnia. Further, this reduction in depression remained stable 3 months after completing CBT-I. This suggests that a CBT-I intervention has a meaningful effect on depression.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Title: Cognitive Behavioral Therapy +/- Armodafinil for Insomnia and Fatigue Following Chemotherapy; Identifier: NCT01091974; URL: https://clinicaltrials.gov/ct2/show/record/NCT01091974.

Social Support, Insomnia, and Adherence to Cognitive Behavioral Therapy for Insomnia After Cancer Treatment

OBJECTIVE/BACKGROUND

While cognitive-behavioral therapy for insomnia (CBT-I) has been shown to be efficacious in treating cancer survivors' insomnia, 30-60% of individuals have difficulty adhering to intervention components. Psychosocial predictors of adherence and response to CBT-I, such as social support, have not been examined in intervention studies for cancer survivors.

PARTICIPANTS

Data from a randomized placebo-controlled 2 x 2 trial of CBT-I and armodafinil (a wakefulness promoting agent) were used to assess adherence. Ninety-six cancer survivors participated in the trial (mean age 56, 86% female, 68% breast cancer).

METHODS

CBT-I and armodafinil were administered over the course of seven weeks, and participants were assessed at baseline, during intervention, postintervention, and at a three-month follow-up. Social support was assessed using a Functional Assessment of Chronic Illness Therapy subscale, insomnia severity was assessed using the Insomnia Severity Index, and adherence was measured based on CBT-I sleep prescriptions.

RESULTS

At baseline, social support was negatively correlated with insomnia severity (r = -0.30, p = 0.002) and associations between social support, CBT-I, and insomnia were maintained through the three-month follow-up. Social support was positively associated with adherence to CBT-I during intervention weeks 3, 4, and 5, and with overall intervention adherence. At postintervention, both social support and treatment with CBT-I independently predicted decreased insomnia severity (p < 0.01) when controlling for baseline insomnia severity.

CONCLUSIONS

Higher social support is associated with better intervention adherence and improved sleep independent of CBT-I. Additional research is needed to determine whether social support can be leveraged to improve adherence and response to CBT-I.

Cancer Survivors' Beliefs About the Causes of Their Insomnia: Associations of Causal Attributions With Survivor Characteristics

Objectives: Insomnia is common among cancer survivors, yet survivors' beliefs about their insomnia following cancer are largely unknown. This study describes cancer survivors' causal attributions of insomnia and whether these beliefs differ by sociodemographic characteristics. Participants: 160 cancer survivors meeting diagnostic criteria for insomnia disorder. Methods: Survivors endorsed how likely they believed 12 different factors were causally related to their insomnia and self-reported sociodemographics. Multinomial logistic regression tested associations between attribution endorsement and sociodemographics. Latent class analysis (LCA) examined patterns of attribution endorsement and whether sociodemographics were associated. Results: One hundred fifty-four survivors (96%) endorsed that at least 1 causal attribution was likely related to their insomnia. Most survivors endorsed that emotions (77%), thinking patterns (76%), sleep-related emotions (65%), and sleep-related thoughts (57%) were related to their insomnia, similar to data previously published among healthy persons with insomnia. Younger participants were more likely to endorse that biochemical factors related to their insomnia (ps < .02); females were more likely to endorse that hormonal factors related to their insomnia (ps < .001). LCA identified three classes (AIC = 3209.50, BIC = 3485.13). Approximately 40% of survivors endorsed most of the causal attributions were likely related to their insomnia; 13% frequently endorsed attributions were neither likely nor unlikely to be related. Older survivors were more likely to belong to the 47% who reported most attributions were unlikely related to their insomnia (p = .03). Conclusions: Cancer survivors with insomnia commonly endorsed that thoughts and emotions contributed to their sleep disturbance. Survivors' sociodemographic characteristics did not meaningfully explain individual differences for most causal attribution beliefs.

Insomnia among Cancer Caregivers: A Proposal for Tailored Cognitive Behavioral Therapy

Caregivers are relatives, friends, or partners who have a significant relationship with and provide assistance (i.e., physical, emotional) to a patient with often life-threatening, serious illnesses. Between 40 and 76 percent of caregivers for people with cancer experience sleep disturbance. This is thought to be due, in part, to the unique responsibilities, stressors, and compensatory behaviors endemic to caregiving that serve as precipitating and perpetuating factors of insomnia. Sleep disturbances are associated with significant alterations in one's mental and physical health. Once chronic, insomnia does not remit naturally. Cognitive-behavioral therapy for insomnia (CBT-I) is well-suited to address the multifaceted contributing factors unique to caregivers' sleep disturbance, yet only one intervention has tested a CBT-I informed intervention among cancer caregivers. Toward the goal of developing effective, tailored treatments for insomnia in caregivers, we address the distinct presentation of insomnia among cancer caregivers and describe key modifications to standard CBT-I that address these specific needs and enhance sensitivity and feasibility, modeled in a demonstrative case vignette. Future research must seek to provide a wide range of effective treatment options for this population, including internet-based, dyadic, and alternative integrative medicine treatments. Applicability of key modifications for caregivers of patients with other chronic illnesses is discussed. Establishing empirically-supported interventions for insomnia among cancer caregivers has the potential to enhance their quality of life and care provided, lead to improved bereavement outcomes, and attenuate the notable mental and physical health disparities present in this vulnerable population.