Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program

Sleep Disruption and Cancer: Chicken or the Egg?

Sleep is a nearly ubiquitous phenomenon across the phylogenetic tree, highlighting its essential role in ensuring fitness across evolutionary time. Consequently, chronic disruption of the duration, timing, or structure of sleep can cause widespread problems in multiple physiological systems, including those that regulate energy balance, immune function, and cognitive capacity, among others. Many, if not all these systems, become altered throughout the course of cancer initiation, growth, metastatic spread, treatment, and recurrence. Recent work has demonstrated how changes in sleep influence the development of chronic diseases, including cancer, in both humans and animal models. A common finding is that for some cancers (e.g., breast), chronic disruption of sleep/wake states prior to disease onset is associated with an increased risk for cancer development. Additionally, sleep disruption after cancer initiation is often associated with worse outcomes. Recently, evidence suggesting that cancer itself can affect neuronal circuits controlling sleep and wakefulness has accumulated. Patients with cancer often report difficulty falling asleep, difficulty staying asleep, and severe fatigue, during and even years after treatment. In addition to the psychological stress associated with cancer, cancer itself may alter sleep homeostasis through changes to host physiology and via currently undefined mechanisms. Moreover, cancer treatments (e.g., chemotherapy, radiation, hormonal, and surgical) may further worsen sleep problems through complex biological processes yet to be fully understood. This results in a “chicken or the egg” phenomenon, where it is unclear whether sleep disruption promotes cancer or cancer reciprocally disrupts sleep. This review will discuss existing evidence for both hypotheses and present a framework through which the interactions between sleep and cancer can be dissociated and causally investigated.

Mechanisms of Cognitive Behavioral Therapy and Light Therapy for Cancer-Related Insomnia: A Randomized Clinical Trial during Chemotherapy for Breast Cancer

STUDY OBJECTIVES

This study aimed to investigate the mechanisms of a combined brief cognitive behavioral plus bright light therapy (CBT-I+Light) in women receiving chemotherapy.

METHODS

Women (N = 101) were randomly assigned to CBT-I+Light or treatment as usual plus relaxation audios (TAU+). Participants completed sleep diaries and wore an actigraph during the 6-week intervention period. Patient-reported outcomes were assessed at baseline, mid-point (week 3), and later (week 6). Cognitive (i.e., dysfunctional sleep beliefs, pre-sleep cognitions, and arousal) and behavioral (i.e., time in bed awake and day-to-day out-of-bedtime variability) mechanisms were examined.

RESULTS

Cognitively, both groups declined significantly in overall dysfunctional sleep beliefs from pre- to post-intervention (both p< .04); however, they did not differ on sleep-related beliefs nor pre-sleep cognitions and arousal at post-intervention (both p> .50). Dysfunctional beliefs sleep expectations subscale was lower in CBT-I+Light versus TAU+ (p= .01). Behaviorally, CBT-I+Light reported less overall time in bed awake after the start of the intervention (p< .05) and significantly less time in bed during the morning until the final week of the intervention period. Out-of-bedtime day-to-day variability was lower in the CBT-+Light vs TAU+ at the final intervention day.

CONCLUSION

Mechanisms of CBT-I+Light during chemotherapy remain to be shown. Our results suggest that changes in behavioral mechanisms may be associated with sleep improvements within this cohort. Future studies should assess the role of additional mechanisms (e.g., sleep effort) within larger samples. Whilst intervention brevity is important, more potent interventions may be required to achieve robust changes in target mechanisms.

Prevalence of Sleep Disturbance in Patients With Cancer: A Systematic Review and Meta-Analysis

Sleep disturbance is one of the most common and troubling symptoms that harm the quality of life throughout all phases of treatment and stages of the illness among patients with cancer. The aim of this meta-analysis is to examine the present status of sleep disturbance prevalence in patients with cancer. The following databases were searched: PubMed, CINAHL, MEDLINE, EMBASE, PsycINFO, from inception to April 2021. Prevalence rates were pooled with meta-analysis using a random-effects model. A total of 160 studies (N = 46,279) published between 1998 and 2021 met the inclusion criteria. The overall prevalence of sleep disturbance was 60.7% (26,448/46,279 participants, 95% CI 58.1–63.3%) with significant heterogeneity between studies (p < .000, τ² = .0000, I² = 96.4%). This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce sleep disturbance and improve the quality of life of cancer patients.

Sleep During Oncological Treatment – A Systematic Review and Meta-Analysis of Associations With Treatment Response, Time to Progression and Survival

Introduction

Disrupted sleep and sleep-wake activity are frequently observed in cancer patients undergoing oncological treatment. These disruptions are often associated with aggravated symptom burden and diminished health-related quality of life that in turn may compromise treatment adherence and, thus, effectiveness. In addition, disrupted sleep has been linked to carcinogenic processes, which ultimately could result in worse prognostic outcomes.

Aims

Our aim was to systematically review and conduct a meta-analysis of studies examining the associations between sleep and sleep-wake activity and prognostic outcomes in cancer patients undergoing oncological treatment.

Methods

A comprehensive systematic search of English language papers was undertaken in June 2020 using PubMed, The Cochrane Library, and CINAHL. Two reviewers independently screened 4,879 abstracts. A total of 26 papers were included in the narrative review. Thirteen papers reporting hazard ratios reflecting associations between a dichotomized predictor variable (sleep) and prognostic outcomes were subjected to meta-analysis.

Results

Nineteen of the 26 eligible studies on a total of 7,092 cancer patients reported associations between poorer sleep and poorer response to treatment, shorter time to progression, and/or reduced overall survival, but were highly heterogeneous with respect to the sleep and outcome parameters investigated. Meta-analysis revealed statistically significant associations between poor self-reported sleep and reduced overall survival (HR = 1.33 [95% CI 1.09–1.62], k = 11), and shorter time to progression (HR = 1.40 [95% CI 1.23–1.59], k = 3) and between poor objectively assessed sleep and reduced overall survival (HR = 1.74 [95% CI 1.05–2.88], k = 4).

Conclusion

The current findings indicate that disturbed sleep during treatment may be a relevant behavioral marker of poor cancer prognosis. The limited number of studies, the common use of single item sleep measures, and potential publication bias highlight the need for further high quality and longitudinal studies.

Exploring the links among inflammation and gut microbiome with psychoneurological symptoms and gastrointestinal toxicities in gynecologic cancers: a systematic review

INTRODUCTION

Emerging evidence highlights the roles the gut microbiome and the immune system, integral parts of the gut-brain axis, play in developing various symptoms in cancer patients. The purpose of this systematic review was to describe the roles of inflammatory markers and the gut microbiome, as well as to describe their associations with psychoneurological symptoms and gastrointestinal toxicities in women with gynecologic cancers.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, and Web of Science from January 2000 to February 2021. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were utilized to screen the found articles. The quality of the included studies was assessed using the Mixed Method Assessment Tool. In the included studies, various inflammatory markers and gut microbiome diversity and patterns were measured.

RESULTS

Sixteen studies met the eligibility criteria and were included in this systematic review. While there were discrepancies in the associations between various inflammatory markers and symptoms, most of the studies showed positive correlations between interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) and cancer-related psychoneurological symptoms and gastrointestinal toxicities in gynecologic cancer patients. Although there was no consensus in alpha diversity, studies showed significant dissimilarity in the microbial communities (beta diversity) in patients with gastrointestinal toxicities compared with patients without symptoms or healthy controls. Studies also reported inconsistent findings in the abundance of bacteria at different taxonomic levels. Radiation enteritis-derived microbiota could stimulate TNF-α and interleukin 1 beta (IL-1β) secretion.

CONCLUSIONS

Alteration of inflammatory markers, the gut microbiome, and their associations show emerging evidence in the development of psychoneurological symptoms and gastrointestinal toxicities in women with gynecologic cancers. More studies on the interactions between the immune system and the gut microbiome, two integral parts of the gut-brain axis, are required to shed light on the roles they play in symptom development.

Quelle est la place des professionnels de santé dans l’adhésion aux programmes thérapeutiques en ligne de l’insomnie ? Éléments de réflexion issus de l’étude Sleep-4-All-1 et protocole de l’étude Sleep-4-All-2.0

La thérapie cognitivocomportementale de l’insomnie (TCC-I) demeure difficile d’accès pour les patients atteints de cancer. Sa digitalisation semble une solution prometteuse pour bénéficier au plus grand nombre. La faisabilité d’un programme TCC-I québécois a été démontrée en France, tout en révélant les limites d’un dispositif suivi en autonomie et à distance. L’enjeu reste de mieux comprendre le rôle des professionnels de santé dans l’accompagnement des patients dans ce type de programme. C’est l’objectif de l’étude Sleep-4-All-2.0 dont nous présenterons ici le protocole.

Sleep and gynecological cancer outcomes: opportunities to improve quality of life and survival

Sleep is important for immune function, metabolic function and physical repair. Sleep is more commonly disrupted in women compared with men and is disrupted by surgery, chemotherapy, and cancer itself, making gynecological oncology patients at higher risk of insomnia and sleep disruption. Insomnia and sleep disruption are linked to increased pain, poorer quality of life, depression, and anxiety which can all negatively affect patient outcomes. A number of environmental, behavioral, and pharmacological interventions have been investigated to improve patient sleep and aid in the recovery process. It is vital to understand and address patient sleep quality in order to give patients the highest quality care and improve outcomes.

Preventing Sleep Disruption With Bright Light Therapy During Chemotherapy for Breast Cancer: A Phase II Randomized Controlled Trial

Purpose

The goal of this study was to examine whether daily increased morning light exposure would maintain or improve sleep and the circadian pattern of relatively more activity in the day and less during the night in women undergoing chemotherapy for breast cancer.

Patients and Methods

Participants were 39 women with newly diagnosed breast cancer, randomized to either 30-mins of daily morning bright white light (BWL) or dim red light (DRL). Sleep/wake was measured objectively for 72-h with wrist actigraphy and subjectively with the Pittsburgh Sleep Quality Index (PSQI) prior to and during chemotherapy cycles 1 and 4. The study was registered with the National Institutes of Health ClinicalTrials.gov (Clinical Trials number: NCT00478257).

Results

Results from actigraphy suggested that compared to the DRL group, women in the BWL group had longer night-time sleep, fewer sleep disturbances during the night, and had fewer and shorter daytime naps at the end of cycle 4 of chemotherapy as well as exhibiting less activity at night and more activity during the day by the end of cycle 4. Results from PSQI indicated that components of sleep quality improved but daytime dysfunction deteriorated during cycle 4 treatment in the BWL group; meanwhile the DRL group used more sleep medications in the treatment weeks which might have led to the improved sleep quality during the recovery weeks of both cycles.

Conclusion

These results suggest that bright white light therapy administered every morning on awakening may protect women undergoing chemotherapy for breast cancer from nighttime sleep and daytime wake disruption. Randomized clinical trials in larger samples are needed to confirm these findings.

Tanshinone IIA: New Perspective on the Anti-Tumor Mechanism of A Traditional Natural Medicine

The search for natural and efficacious antineoplastic drugs, with minimal toxicity and side effects, is an important part of antitumor drug research and development. Tanshinone IIA is the most evaluated lipophilic active component of Salvia miltiorrhiza. Tanshinone IIA is a path-breaking traditional drug applied in cardiovascular treatment. It has also been found that tanshinone IIA plays an important role in the digestive, respiratory and circulatory systems, as well as in other tumor diseases. Tanshinone IIA significantly inhibits the proliferation of several types of tumors, blocks the cell cycle, induces apoptosis and autophagic death, in addition to inhibiting cell migration and invasion. Among these, the regulation of tumor-cell apoptosis signaling pathways is the key breakthrough point in several modes of antitumor therapy. The PI3K/AKT/MTOR signaling pathway and the JNK pathway are the key pathways for tanshinone IIA to induce tumor cell apoptosis. In addition to glycolysis, reactive oxygen species and signal transduction all play an active role with the participation of tanshinone IIA. Endogenous apoptosis is considered the main mechanism of tumor apoptosis induced by tanshinone IIA. Multiple pathways and targets play a role in the process of endogenous apoptosis. Tanshinone IIA can protect chemotherapy drugs, which is mainly reflected in the protection of the side effects of chemotherapy drugs, such as neurotoxicity and inhibition of the hematopoietic system. Tanshinone IIA also has a certain regulatory effect on tumor angiogenesis, which is mainly manifested in the control of hypoxia. Our findings indicated that tanshinone IIA is an effective treatment agent in the cardiovascular field and plays a significant role in antitumor therapeutics. This paper reviews the pharmacological potential and inhibitory effect of tanshinone IIA on cancer. It is greatly anticipated that tanshinone IIA will be employed as an adjuvant in the treatment of various cancers.

Cannabidiol (CBD) in Cancer Management

Simple Summary

Cannabidiol (CBD) is one of the main constituents of the plant Cannabis sativa. Surveys suggest that medicinal cannabis is popular amongst people diagnosed with cancer. CBD is one of the key constituents of cannabis, and does not have the potentially intoxicating effects that tetrahydrocannabinol (THC), the other key phytocannabinoid has. Research indicates the CBD may have potential for the treatment of cancer, including the symptoms and signs associated with cancer and its treatment. Preclinical research suggests CBD may address many of the pathways involved in the pathogenesis of cancers. Preclinical and clinical research also suggests some evidence of efficacy, alone or in some cases in conjunction with tetrahydrocannabinol (THC, the other key phytocannabinoid in cannabis), in treating cancer-associated pain, anxiety and depression, sleep problems, nausea and vomiting, and oral mucositis that are associated with cancer and/or its treatment. Studies also suggest that CBD may enhance orthodox treatments with chemotherapeutic agents and radiation therapy and protect against neural and organ damage. CBD shows promise as part of an integrative approach to the management of cancer.

Abstract

The plant Cannabis sativa has been in use medicinally for several thousand years. It has over 540 metabolites thought to be responsible for its therapeutic effects. Two of the key phytocannabinoids are cannabidiol (CBD) and tetrahydrocannabinol (THC). Unlike THC, CBD does not have potentially intoxicating effects. Preclinical and clinical research indicates that CBD has a wide range of therapeutic effects, and many of them are relevant to the management of cancer. In this article, we explore some of the potential mechanisms of action of CBD in cancer, and evidence of its efficacy in the integrative management of cancer including the side effects associated with its treatment, demonstrating its potential for integration with orthodox cancer care.

Sleep moderates the effects of Tibetan yoga for women with breast cancer undergoing chemotherapy

This study examined self-reported and actigraphy-assessed sleep and depression as moderators of the effect of a Tibetan yoga intervention on sleep and depression among women undergoing chemotherapy for breast cancer. This is a secondary analysis of an RCT examining a 4-session Tibetan yoga program (TYP; n = 74) versus stretching program (STP; n = 68) or usual care (UC; n = 85) on self-reported sleep (Pittsburgh Sleep Quality Index (PSQI), actigraphy-assessed sleep efficiency (SE)) and depression (Centers for Epidemiological Studies Depression Scale; CES-D) for women undergoing chemotherapy for breast cancer. Data were collected at baseline and 1-week and 3-month post-intervention. Baseline PSQI, actigraphy-SE, and CES-D were examined as moderators of the effect of group on PSQI, actigraphy-SE, and CES-D 1 week and 3 months after treatment. There was a significant baseline actigraphy-SE × group effect on PSQI at 1 week (p < .001) and 3 months (p = .002) and on CES-D at 3 months (p = .049). Specifically, the negative association of baseline actigraphy-SE with subsequent PSQI and CES-D was buffered for women in the TYP and, to a lesser extent in STP, compared to those in the UC. Baseline PSQI and CES-D were not significant moderators of the effect of group on any outcome. Behaviorally assessed sleep may be a more robust indicator of which patients are most appropriate for a yoga intervention than self-reported sleep quality. Women with poor sleep efficiency may derive the greatest benefit in terms of sleep quality and mood from a yoga intervention.

Prospective Rates, Longitudinal Associations, and Factors Associated With Comorbid Insomnia Symptoms and Perceived Cognitive Impairment

Background

Insomnia and cognitive impairment are both common conditions experienced by people diagnosed with cancer. Individually, these conditions have negative impacts on functioning, but the combined burden has yet to be evaluated. The purpose of this research was to estimate rates of comorbid insomnia and perceived cognitive impairments, examine the longitudinal associations between these two conditions, and identify demographic and clinical factors associated with reporting both insomnia and perceived cognitive impairment.

Methods

In this secondary analysis, a heterogeneous sample of 962 patients completed the Insomnia Severity Index (ISI) and the Cognitive Failures Questionnaire (CFQ) at the time of their cancer surgery (baseline; T1) and then again at 2 (T2), 6 (T3), 10 (T4), 14 (T5), and 18 (T6) months. Correlations and partial correlations, controlling for age and education level, were computed at each time point to assess the relationship between ISI and CFQ scores. Cross-lagged correlations assessed associations between ISI and CFQ scores over time. Proportions of patients with comorbid insomnia and cognitive impairments were calculated and logistic regressions investigated changes over time in these proportions. ANOVAs, logistic regressions, ordinal regressions, and multinomial regressions were used to identify risk factors of having comorbid insomnia and cognitive difficulties.

Results

Significant and bidirectional correlations between ISI and CFQ scores were observed at each time point and over time. The proportion of patients having both clinical levels of insomnia and perceived cognitive difficulties ranged from 18.73 to 25.84% across time points and this proportion was significantly greater at T1 and T2 than T4, T5, and T6. Participants who reported comorbid insomnia and cognitive impairment were more likely to be younger, female, not currently working, currently receiving chemotherapy, with clinical levels depression and anxiety, and using antidepressants or anxiolytics.

Conclusion

Comorbid insomnia and perceived cognitive impairment affects around one in five patients and is more frequent at the beginning of the cancer care trajectory. The relationship between insomnia and cognitive impairment appears to be bidirectional. Insomnia may represent an important patient level vulnerability that when identified and treated can improve perception of cognitive function.

The safety and efficacy of using moxibustion and or acupuncture for cancer-related insomnia: a systematic review and meta-analysis of randomised controlled trials

Introduction:

This study aimed to synthesise the best available evidence on the safety and efficacy of using moxibustion and/or acupuncture to manage cancer-related insomnia (CRI).

Methods:

The PRISMA framework guided the review. Nine databases were searched from its inception to July 2020, published in English or Chinese. Randomised clinical trials (RCTs) of moxibustion and or acupuncture for the treatment of CRI were selected for inclusion. Methodological quality was assessed using the method suggested by the Cochrane collaboration. The Cochrane Review Manager was used to conduct a meta-analysis.

Results:

Fourteen RCTs met the eligibility criteria. Twelve RCTs used the Pittsburgh Sleep Quality Index (PSQI) score as continuous data and a meta-analysis showed positive effects of moxibustion and or acupuncture (n = 997, mean difference (MD) = −1.84, 95% confidence interval (CI) = −2.75 to −0.94, p < 0.01). Five RCTs using continuous data and a meta-analysis in these studies also showed significant difference between two groups (n = 358, risk ratio (RR) = 0.45, 95% CI = 0.26–0.80, I² = 39%).

Conclusion:

The meta-analyses demonstrated that moxibustion and or acupuncture showed a positive effect in managing CRI. Such modalities could be considered an add-on option in the current CRI management regimen.

The top 100 most cited papers in insomnia: A bibliometric analysis

OBJECTIVE

The number of citations to a paper represents the weight of that work in a particular area of interest. Several highly cited papers are listed in the bibliometric analysis. This study aimed to identify and analyze the 100 most cited papers in insomnia research that might appeal to researchers and clinicians.

METHODS

We reviewed the Web of Science (WOS) Core Collection database to identify articles from 1985 to 24 March 2022. The R bibliometric package was used to further analyze citation counts, authors, year of publication, source journal, geographical origin, subject, article type, and level of evidence. Word co-occurrence in 100 articles was visualized using VOS viewer software.

RESULTS

A total of 44,654 manuscripts were searched on the Web of Science. Between 2001 and 2021, the top 100 influential manuscripts were published, with a total citation frequency of 38,463. The top countries and institutions contributing to the field were the U.S. and Duke University. Morin C.M. was the most productive author, ranking first in citations. Sleep had the highest number of manuscripts published in the top 100 (n = 31), followed by Sleep Medicine Reviews (n = 9). The most cited manuscript (Bastien et al., Sleep Medicine, 2001; 3,384 citations) reported clinical validation of the Insomnia Severity Index (ISI) as a brief screening indicator for insomnia and as an outcome indicator for treatment studies. Co-occurrence analyses suggest that psychiatric disorders combined with insomnia and cognitive behavioral therapy remain future research trends.

CONCLUSION

This study provides a detailed list of the most cited articles on insomnia. The analysis provides researchers and clinicians with a detailed overview of the most cited papers on insomnia over the past two decades. Notably, COVID-19, anxiety, depression, CBT, and sleep microstructure are potential areas of focus for future research.

Sleep Quality and Associated Factors Among Adult Cancer Patients Under Treatment at Oncology Units in Amhara Region, Ethiopia

INTRODUCTION

Poor sleep quality, a common, under-diagnosed, and under-treated problem in cancer patients, has negative physical and psychological consequences, but its prevalence and associated factors are not well studied in Ethiopia. Thus, the present study aimed to assess the prevalence of sleep quality and its associated factors among adult cancer patients receiving treatment at oncology units in Amhara region, Ethiopia.

METHODS AND MATERIALS

An institution-based cross-sectional study was conducted among adult patients with cancer under treatment at the oncology units in the Amhara region from April 12 to May 12/2021. A systematic random sampling technique was used to select 423 samples. Data were collected using a structured Interviewer-administered questionnaire. Sleep quality and depression were assessed by the Pittsburgh Sleep Quality Index and depression subscale of Hospital Anxiety and Depression Scale, respectively. Bivariable and multivariable logistic regression analyses were computed, considering p < 0.25 to select candidate variables for multivariable analysis and p < 0.05 to be statistically significant in the final model.

RESULTS

A total of 410 cancer patients participated in this study. The mean of the participant's age was 44.2 (range: 20-77) years. More than half (52.7%) of participants received chemotherapy and the remaining were treated with a combination of treatments. Two-hundred ninety-three (71.5%) of participants had poor sleep quality and 28.5% had good sleep quality. The factors found to be significantly associated with poor sleep quality were advanced age [AOR = 1.037, 95% CI: (1.012-1.062)]; having depressive symptoms [AOR = 2.862, 95% CI: (1.133, 7.228)]; having distant metastasis cancer [AOR = 3.758, 95% CI: (1.585, 8.909)]; and increased severity of pain [AOR = 1.331, 95% CI: (1.106, 1.601)].

CONCLUSION

The study found a high prevalence of poor sleep quality among cancer patients. Early screening and management of sleep problems are crucial in patients with cancer.

Impacts of Cognitive Behavioral Therapy for Insomnia and Pain on Sleep in Women with Gynecologic Malignancies: A Randomized Controlled Trial

Insomnia is an adverse cancer outcome impacting mood, pain, quality of life, and mortality in cancer patients. Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for diverse psychophysiological disorders, including pain and insomnia. Primarily studied in breast cancer, there is limited research on CBT within gynecology oncology. This study examined CBT effects on subjective and behavioral sleep outcomes: Sleep Efficiency (SE), Sleep Quality (SQ), Total Wake Time (TWT), Sleep Onset Latency (SOL), and Wake After Sleep Onset (WASO). Thirty-five women with insomnia status/post-surgery for gynecologic cancer were randomized to CBT for insomnia and pain (CBTi.p., N = 18) or Psychoeducation (N = 17). Sleep was assessed via sleep diaries and wrist-worn actigraphy at baseline (T1), post-intervention (T2), and two-month follow-up (T3). Intent-to-treat analyses utilizing mixed linear modeling examined longitudinal group differences on sleep controlling for age and advanced cancer. All participants demonstrated improved (1) subjective SE (0.5, p < .01), SOL (-1.2, p < .01), TWT (-1.2, p < .01), and (2) behavioral SE (0.1, p = .02), TWT (-1.2, p = .03), WASO (-0.8, p < .01) across time. Group-level time trends were indicative of higher subjective SE (6.8, p = .02), lower TWT (-40.3, p = .01), and lower SOL (-13.0, p = .05) in CBTi.p. compared to Psychoeducation. Supplemental analyses examining clinical significance and acute treatment effects demonstrated clinical improvements in SE (T1), TWT (T2, T3), and SOL (T3). Remaining effects were not significant. Despite lacking power to detect interaction effects, CBTi.p. clinically improved sleep in women with gynecologic cancers and insomnia during the active treatment phase. Future research will focus on developing larger trials within underserved populations.

A multidisciplinary perspective on the complex interactions between sleep, circadian, and metabolic disruption in cancer patients

Sleep is a basic need that is frequently set aside in modern societies. This leads to profound but complex physiological maladaptations in the body commonly referred to as circadian disruption, which recently has been characterized as a carcinogenic factor and reason for poor treatment outcomes, shortened survival, and reduced quality of life in cancer patients. As sleep and circadian physiology in cancer patients spans several disciplines including nursing science, neurology, oncology, molecular biology and medical technology, there is a lack of comprehensive and integrated approaches to deal with this serious and growing issue and at best a fractionated understanding of only part of the problem among researchers within each of these segments. Here, we take a multidisciplinary approach to comprehensively review the diagnosis and impact of sleep and circadian disruption in cancer patients. We discuss recent discoveries on molecular regulation of the circadian clock in healthy and malignant cells, the neurological and endocrine pathways controlling sleep and circadian rhythmicity, and their inputs to and outputs from the organism. The benefits and drawbacks of the various technologies, devices, and instruments used to assess sleep and circadian function, as well as the known consequences of sleep disruption and how sleep can be corrected in cancer patients, will be analyzed. We will throughout the review highlight the extensive crosstalk between sleep, circadian rhythms, and metabolic pathways involved in malignancy and identify current knowledge gaps and barriers for addressing the issue of sleep and circadian disruption in cancer patients. By addressing these issues, we hope to provide a foundation for further research as well as better and more effective care for the patients in the future.

A prospective interventional study investigating sleep disorders prior to and during adjuvant radiotherapy for breast cancer

BACKGROUND

Most breast cancer patients with non-metastatic disease receive adjuvant local or loco-regional radiotherapy. To be scheduled for irradiation may cause distress and fears that can lead to sleep disorders. Few reports focused on sleep problems in patients assigned to radiotherapy. This study evaluates the course of sleep disorders during adjuvant radiotherapy for primary breast cancer and potential risk factors including the use of smartphones or tablets at bedtime.

METHODS

The main goal is the evaluation of sleep disorders prior to radiotherapy and after 15 fractions of radiotherapy. A potential effect of habituation to the procedure of radiotherapy can be assumed that will likely lead to improvement (decrease) of sleep disorders. Improvement of sleep disorders (compared to baseline before radiotherapy) is defined as decrease of the severity of sleep disorders by ≥2 points on a patient self-rating scale (0 = no problems; 10 = maximum problems) or decrease of distress caused by sleep disorders by ≥2 points on a self-rating scale (0 = no distress; 10 = maximum distress) or reduction of the dose of sleeping drugs by ≥25%. Additional endpoints include sleep disorders after 5 fractions and at the end of radiotherapy. Moreover, potential risk factors including the use of smartphones or tablets at bedtime are evaluated. Fifty-one patients (48 plus potential drop-outs) are required. With this sample size, a one-sample binomial test with a one-sided significance level of 2.5% has a power of 80% to yield statistical significance, if the rate of patients with improvement of sleep disorders is 25% (rate under the alternative hypothesis) and assuming that a decrease of ≤10% has to be judged as a random, non-causal change in this uncontrolled study setting (null hypothesis).

DISCUSSION

If a decrease of sleep disorders during the course of radiotherapy is shown, this aspect should be included in the pre-radiotherapy consent discussion with the patients. Moreover, identification of additional risk factors will likely lead to earlier psychological support. If the use of smartphones or tablets at bedtime is a risk factor, patients should be advised to change this behavior.

TRIAL REGISTRATION

clinicaltrials.gov (NCT04879264; URL: https://clinicaltrials.gov/show/NCT04879264 ); registered on 7th of May, 2021.

Electroacupuncture Plus Auricular Acupressure on Chemotherapy-Related Insomnia in Patients With Breast Cancer (EACRI): Study Protocol for a Randomized, Sham-Controlled Trial

OBJECTIVE

Insomnia is a highly prevalent and disturbing symptom in breast cancer patients under or post chemotherapy. If not appropriately treated, it can persist for years after the completion of cancer treatments. Acupuncture has been widely used for alleviating insomnia. The aim of this study is to examine the feasibility, efficacy and safety of acupuncture for chemotherapy-related insomnia among patients with breast cancer.

MATERIALS AND METHODS

This is a trial protocol for a randomized, sham-controlled, subject- and assessor-blinded clinical trial. A total of 138 eligible participants will be assigned randomly to acupuncture or sham control group at a ratio of 1:1. Participants in acupuncture group will receive electroacupuncture (EA) plus auricular acupressure (AA) treatment, while subjects in sham acupuncture group will receive sham EA plus sham AA. Both acupuncture and sham treatments will be given twice weekly for 6 weeks, followed by maintenance treatments once every 4 weeks for 12 weeks (15 sessions totally). The primary outcome is the change of Insomnia Severity Index score between baseline and the end of 6-week treatment. Secondary outcome measurements include Actiwatch, sleep diary, Pittsburgh Sleep Quality Index, Functional Assessment of Cancer Therapy-Breast Cancer, Hospital Anxiety and Depression Scale, Brief Pain Inventory-Short Form, Brief Fatigue Inventory, Acupuncture Expectancy Scale, credibility, and adverse events. Participants will be followed up to 42 weeks.

CONCLUSIONS

This trial will expand our understanding of the feasibility, efficacy, and safety of acupuncture as a treatment for alleviating chemotherapy-related insomnia in patients with breast cancer. EA plus AA, if proven to be effective, can be implemented into routine settings to play a role in insomnia management for patients with breast cancer.

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial

STUDY OBJECTIVES

Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I).

METHODS

A total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step.

RESULTS

Results indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores.

CONCLUSION(S)

The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).

Sleep disturbance in cancer patients referred to an ambulatory integrative oncology consultation

BACKGROUND

Sleep disturbance (SD) is highly prevalent in oncology and negatively affects quality of life and mortality. Evidence supports the use of integrative oncology (IO) practices to treat SD, but there is limited published data on the characteristics of SD and factors associated with SD in IO. We determined the prevalence, severity, and factors associated with SD among cancer patients seen in an ambulatory IO consultation.

METHODS

Patients with cancer referred for initial outpatient IO consultation in 2017 were eligible. Patient demographics, clinical characteristics, and patient-reported outcomes (Edmonton Symptom Assessment Scale (ESAS), Measure Yourself Concerns and Wellbeing (MYCaW), PROMIS-10) were retrospectively reviewed.

RESULTS

One thousand five hundred twenty patients were included in the analysis. The majority (70%) were women with breast cancer (42%). Nine hundred seventy-one (64%) patients reported significant SD with ESAS Sleep ≥ 4, yet only 11% expressed poor sleep as their primary or secondary concern for the IO consultation. The median SD (IQR) was 5 (3,7). ESAS scores for fatigue (adjusted OR 1.16; CI 1.07-1.26, p < 0.001), pain (adjusted OR 1.07; CI 1.00-1.15, p < 0.05), hot flashes (adjusted OR 1.14; CI 1.07-1.22, p < 0.001), well-being (adjusted OR 1.33; CI 1.22-1.46, p < 0.001), and psychological distress score (anxiety and depression) (adjusted OR 1.16; CI 1.01-1.11, p < 0.01) were independently associated with SD in multivariate analysis. Acupuncture was the most frequent intervention prescribed, 175 (35%). Other modalities included oncology massage (15%), health psychology (5%), and meditation (1%).

CONCLUSIONS

Although 64% of patients seeking IO consultation reported clinically significant SD, only 11% were seeking integrative approaches for managing SD. ESAS fatigue, hot flashes, well-being, and psychological symptoms were significantly associated with SD.

Sleep Disorders in Cancer-A Systematic Review

INTRODUCTION

Sleep disorders, especially insomnia, are very common in different kinds of cancers, but their prevalence and incidence are not well-known. Disturbed sleep in cancer is caused by different reasons and usually appears as a comorbid disorder to different somatic and psychiatric diagnoses, psychological disturbances and treatment methods. There can be many different predictors for sleep disturbances in these vulnerable groups, such as pre-existing sleep disorders, caused by the mental status in cancer or as side effect of the cancer treatment.

METHODS

A systematic literature review of 8073 studies was conducted on the topic of sleep and sleep disorders in cancer patients. The articles were identified though PubMed, PsycInfo and Web of Knowledge, and a total number of 89 publications were qualified for analysis.

RESULTS

The identified eighty-nine studies were analyzed on the topic of sleep and sleep disorders in cancer, twenty-six studies on sleep and fatigue in cancer and sixty-one studies on the topic of sleep disorders in cancer. The prevalence of sleep disturbences and/or sleep disorders in cancer was up to 95%.

DISCUSSION

Sleep disturbances and sleep disorders (such as insomnia, OSAS, narcolepsy and RLS; REM-SBD) in cancer patients can be associated with different conditions. Side effects of cancer treatment and cancer-related psychological dysfunctions can be instigated by sleep disturbances and sleep disorders in these patients, especially insomnia and OSAS are common. An evidence-based treatment is necessary for concomitant mental and/or physical states.

The Therapeutic Effects of Acupuncture and Electroacupuncture on Cancer-related Symptoms and Side-Effects

In addition to cancer-related death, malignant progression also leads to a series of symptoms and side-effects, which would detrimentally affect cancer patients' the quality of life, adversely influence their adherence to treatments, and, therefore, negatively affect their long-term survival. Acupuncture and electroacupuncture (EA), as two classic treatment methods in traditional Chinese medicine, have been widely employed to cure various diseases. Recently, the clinical application of acupuncture and EA in cancer patients has received great attention. In this review, we summarized the clinical application of acupuncture and EA in alleviating the cancer symptoms, reducing the cancer treatment-related side-effects, and relieving the cancer pain. The symptoms and side-effects discussed in this review include fatigue, insomnia, chemotherapy-associated dyspepsia syndrome (CADS), pain, xerostomia, and anxiety and depression. The underlying mechanisms of the therapeutic effects of acupuncture and EA might be related to the regulation of the mitochondrial function, coordination of the activity of the nervous system, adjustment of the production of neurotransmitters, and alleviation of the immune responses. In conclusion, acupuncture and EA have been proved to be beneficial for cancer patients. More research, however, is required to clarify the potential mechanisms behind acupuncture and EA for widespread adoption in clinical application.

Light Enhanced Cognitive Behavioral Therapy (CBT-I+Light) for Insomnia and Fatigue During Chemotherapy for Breast Cancer: A Randomized Controlled Trial

STUDY OBJECTIVES

Sleep problems are common during chemotherapy for breast cancer (BC). We evaluated whether combined brief cognitive behavioral and bright light therapy (CBT-I+Light) is superior to treatment as usual with relaxation audio (TAU+) for insomnia symptoms and sleep efficiency (primary outcomes).

METHODS

We randomized women receiving intravenous chemotherapy, stratified by tumor stage and insomnia severity index (ISI), to 6-weeks CBT-I+Light or TAU+. CBT-I+Light included one in-person session, one telephone call, seven emails, and 20 minutes bright light each morning. TAU+ comprised usual treatment and two emails with relaxation audio tracks. Patient-reported outcomes were assessed at baseline, midpoint (week 3), post (week 6) and 3-month follow-up.

RESULTS

Women (N = 101) were randomly assigned to CBT-I+Light or TAU+. The CBT-I+Light group showed significantly greater improvement in insomnia symptoms than the TAU+ group (-5.06 vs -1.93, P = .009; between-group effect size [ES] = .69). At 3-month follow-up, both groups were lower than baseline but did not differ from each other (between-group ES = .18, P = .56). CBT-I+Light had higher patient-reported sleep efficiency than TAU+ immediately after the start of intervention (P = .05) and significantly greater improvement in fatigue (between-group ES = .59, P = .013) and daytime sleep-related impairment (between-group ES = .61, P = .009) than the TAU+ group.

CONCLUSION

CBT-I+Light had a clinically significant impact on insomnia and fatigue with moderate effect sizes. Results support offering cognitive behavioral therapy for insomnia and bright light therapy during chemotherapy for breast cancer to help manage sleep and fatigue.

Sleep medication use and risk of fractures in breast cancer survivors

Purpose

Sleep problems are more common in breast cancer survivors than those without a cancer history. Our goal was to examine the risk of fractures among breast cancers survivors who used prescription sleep aids.

Methods

We conducted a retrospective cohort study of 21,346 adult women diagnosed with stage 0–III breast cancer between 2009 and 2016 and followed them through 2017. We examined person-year rates of fractures by sleep medication use and calculated adjusted hazard ratios (HR) and 95% confidence intervals (CI) with Cox proportional hazards models using time-dependent variables for sleep medications and covariate medications (antidepressants, anti-anxiety medications, and bisphosphonates) adjusted for demographics, comorbidities, and tumor characteristics and cancer treatments.

Results

The sleep medication use was common (40%) in breast cancer survivors and was associated with a 33% increased risk of fractures (adjusted HR = 1.33, 95% CI: 1.20–1.49). Further, in a sensitivity analysis based on new use of sleep medication, the fracture risk was even stronger (adjusted HR = 1.44, 95% CI: 1.26–1.64).

Conclusion

Given the high use of sleep medications and the high risk of fractures in breast cancer survivors, this study suggests that non-pharmacologic management of sleep problems might be considered as alternative therapy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10549-021-06392-4.

Distinct sleep disturbance profiles among patients with gynecologic cancer receiving chemotherapy

OBJECTIVE

In a sample of patients with gynecologic cancer receiving chemotherapy, we sought to identify subgroups of patients with distinct sleep disturbance profiles and assess for differences in patient characteristics and the severity of co-occurring symptoms among these subgroups.

METHODS

Adults with gynecologic cancer (n = 232) completed questionnaires six times over two chemotherapy cycles. Sleep disturbance was assessed using the General Sleep Disturbance Scale (GSDS). Clinically meaningful sleep disturbance was defined as a GSDS total score of ≥43. Subgroups of patients with distinct sleep disturbance profiles were identified using latent profile analysis. Differences in patient characteristics and co-occurring symptoms were assessed using Chi-square, Kruskal Wallis, and one-way analysis of variance.

RESULTS

Four distinct sleep disturbance profiles were identified: Low (18.5%), Moderate (43.6%), High (29.3%), and Very High (8.6%). Compared to the Low class, patients in the other three classes had lower functional status scores and higher levels of depressive symptoms, trait anxiety, and morning and evening fatigue. Compared to the Low class, patients in the Very High class were younger, had a higher body mass index, and were more likely to report a diagnosis of depression or back pain.

CONCLUSIONS

Over 80% of the patients with gynecologic cancer reported sleep disturbance that persisted over two cycles of chemotherapy. Patients in the Very High class experienced problems with both sleep initiation and maintenance. Clinicians should routinely assess sleep disturbance alongside depression, anxiety, and fatigue. Interventions that target the underlying mechanisms of these co-occurring symptoms are warranted.

Psychosocial Needs and Experiences of Transgender and Gender Diverse People with Cancer: A Scoping Review and Recommendations for Improved Research and Care

The psychosocial needs and experiences of transgender and gender diverse (TGD) people is an understudied area of oncology research. In response to calls to action from past researchers, we conducted a scoping review, which included published and gray literature. From the included articles, the following key themes were identified: (1) lack of coordination between gender-affirming care and cancer care; (2) impact of cancer care on gender affirmation; (3) navigating gendered assumptions; (4) variation in providers' understanding of the needs of TGD patients; and (5) lack of TGD-specific cancer resources. Following this review, we consulted 18 key stakeholders with TGD-relevant personal and/or professional experience to gain further insight into issues that were not encompassed by the original themes. Based on these themes and stakeholder feedback, we offer recommendations for future research and clinical practice to increase awareness of the psychosocial needs of TGD people who have been diagnosed with cancer and to improve patient care.

Exercise intervention in cancer patients with sleep disturbances scheduled for elective surgery: Systematic review

BACKGROUND & OBJECTIVES

Sleep disturbance is one of the patients' major complaints after major surgery and can impair postoperative recovery. Pre-operative exercise has been shown to increase functional capacity and resilience in cancer patients; scarce knowledge is available on the effects of pre-operative exercise on sleep disturbances. This systematic review aims to determine the impact of pre-operative exercise training alone or as part of multimodal prehabilitation on sleep disturbances and sleep quality in cancer patients.

METHODS

A systematic search including Biosis, Cochrane Library and CENTRAL, EMBASE, MEDLINE, and clinical trial registries (clinicaltrials.gov, International Clinical Trials Registry Platform) was performed to identify studies involving a pre-operative exercise intervention in cancer patients awaiting surgery. Trials had to contain at least one sleep measure, assessed subjectively and objectively were included in the systematic review. The quality of the included trials was assessed using the Cochrane Risk of Bias Tool for assessing the risk of bias in randomized trials tool and the ROBINS-I tool for evaluating the risk of bias in non-randomized studies.

RESULTS

Seven studies were included (1 RCT, 2 non-RCTs and 4 single-arm design). Due to substantial heterogeneity in the interventions across studies, a meta-analysis was not conducted. The available empirical evidence on the presurgical effect of exercise on sleep outcomes is scarce and, overall, suggests that it has a limited effect. Besides, non-significant improvement of the pre-operative exercise on sleep was unique to the studies that used subjective measures to assess sleep disturbances changes during cancer treatment.

CONCLUSION

There are conflicting results and a lack of quality data proving the pre-operative exercise on sleep quality and disturbances. More research is needed in the pre-operative period using clinical sleep disturbances such as insomnia as an inclusion criterion, subjectively and objectively assessed.

Relationship of subjective and objective sleep measures with physical performance in advanced-stage lung cancer patients

Advanced lung cancer patients suffer from deteriorated physical function, which negatively impacts physical and psychological health. As little is known about sleep and physical function in this population, this study aimed to examine the association between subjective and objective sleep parameters and physical function among them. 164 advanced lung cancer patients were included. Objective sleep was measured by actigraphy (measured on non-dominant wrist for 72 h), and subjective sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI). Performance-based physical function was measured by Timed Up and Go Test (TUGT), 6-Minute Walk Test (6MWT), Sit-to-Stand Test, and One-leg Standing Test. Univariable and multivariable regression analyses were employed to examine the association between sleep and physical function. Total sleep time (TST) was significantly associated with the 6MWT (β = 0.259; 95% CI 0.120, 0.398; P < 0.001), TUGT (β = - 0.012; 95% CI = - 0.017, - 0.008; P < 0.001) and Sit-to-Stand Test (β = 0.027; 95% CI = 0.018, 0.035; P < 0.001) after adjustment for multiple covariates. PSQI global score was only significantly associated with TUGT (β = 0.140; 95% CI = 0.000, 0.280; P = 0.050) after adjustment for multiple covariates. Shorter sleep duration significantly predicted poorer physical performance in advanced lung cancer patients, and more attention is required for those with less than 4.3 h of sleep on average.Trial registration: ClinicalTrials.gov, NCT03482323. Registered 29 March 2018, https://clinicaltrials.gov/ct2/show/NCT03482323 ; ClinicalTrials.gov, NCT04119778. Registered 8 October 2019, https://clinicaltrials.gov/ct2/show/NCT04119778 .

Antimetastatic Effects of Ganoderma lucidum Polysaccharide Peptide on B16-F10-luc-G5 Melanoma Mice With Sleep Fragmentation

Ganoderma lucidum (Lingzhi) polysaccharide peptide (GL-pp) is a component of the globally acknowledged traditional Chinese medicine Ganoderma lucidum; Ganoderma lucidum is known for its sedative, hypnotic, immune regulatory, antitumor, and other pharmacological effects. In recent years, sleep disorders have been linked to many diseases and human body disorders, including cancer. Some experimental studies in mice found that sleep fragmentation could promote tumor development and progression. However, effects on GL-pp on tumor metastasis under circumstances of sleep disorders have rarely been studied. Thus, in this study, we used mice with sleep fragmentation (SF) bearing B16-F10-luc-G5 melanoma tumors to investigate the effect of SF on melanoma metastasis. Furthermore, we investigated the antitumor and antimetastatic effects of GL-pp (80 mg/kg) in mice suffering from SF and bearing B16-F10-luc-G5. Then, whole proteomics was used to analyze the differences in protein expression in the lung tissue between SF mice bearing B16-F10-luc-G5 with and without GL-pp administration. High-throughput pyrosequencing of 16S rRNA was also used to analyze the impact of GL-pp on the gut microbiota composition in SF mice bearing B16-F10-luc-G5. Last, the effects of GL-pp on macrophage polarization and TNF-α serum levels were detected. Collectively, we found that SF significantly facilitated the B16-F10-luc-G5 melanoma tumor metastasis in mice, while GL-pp significantly reduced B16-F10-luc-G5 melanoma tumor metastasis under the condition of SF, in which proteomics and gut microbiota had been changed greatly.

Sleep and quality of life in lung cancer patients and survivors

BACKGROUND

Lung cancer patients and survivors are vulnerable to disturbed sleep and impaired quality of life (QOL) across the continuum of illness. Few studies have sought to identify predictors of QOL using well-validated measures of both sleep quality and QOL in this population.

PURPOSE

The purpose of this study was to examine factors associated with lung cancer that are predictive of QOL in adult lung cancer patients and survivors in the outpatient setting.

METHOD

Cross-sectional data collected exclusively in the outpatient setting from three lung cancer clinics in the Northeastern United States were pooled and analyzed. The pooled sample (N = 103) data included cancer type and stage, body mass index, Pittsburgh Sleep Quality Index, and Functional Assessment of Cancer Treatment-Lung information.

RESULTS

Significant correlations between sleep quality, lung cancer symptom severity, and QOL were observed. Sleep quality and lung cancer symptoms were found to be statistically significant predictors of QOL. No significant differences in QOL were found based on cancer type or recruitment source. Demographic factors and cancer stage were also not predictive of overall QOL.

CONCLUSIONS

Lung cancer symptoms and sleep quality were important determinants of QOL in this pooled sample of lung cancer patients and survivors.

IMPLICATIONS FOR PRACTICE

Patients and survivors of lung cancer require routine screening for sleep disturbance, lung cancer symptoms, and QOL needs. Nurse practitioners can help improve QOL in this population by screening for and treating sleep disturbance and lung cancer symptoms.

Evaluation and Management of Sleep and Circadian Rhythm Disturbance in Cancer

OPINION STATEMENT

Sleep and circadian rhythm disturbance are among the most commonly experienced symptoms in patients with cancer. These disturbances occur throughout the spectrum of cancer care from diagnosis, treatment, and long into survivorship. The pathogenesis of these symptoms and disturbances is based on common inflammatory pathways related to cancer and its' treatments. The evaluation of sleep and circadian disorders requires an understanding of how these symptoms cluster with other cancer-related symptoms and potentiate each other. A thorough evaluation of these symptoms and disorders utilizing validated diagnostic tools, directed review of clinical information, and diagnostic testing is recommended. Treatment of sleep and circadian disturbance in cancer patients should be based on the findings of a detailed evaluation, including specific treatment of primary sleep and circadian disorders, and utilize integrative and personalised management of cancer-related symptoms through multiple pharmacologic and non-pharmacologic modalities. Recognition, evaluation, and treatment of sleep and circadian rhythm disturbance in cancer may lead to improved symptom management, quality of life, and outcomes.

Sleep Disorders Before and During the COVID-19 Pandemic in Patients Assigned to Adjuvant Radiotherapy for Breast Cancer

BACKGROUND/AIM

The anticipation of radiotherapy can cause distress and sleep disorders, which may be aggravated by the COVID-19 pandemic. This study investigated sleep disorders in a large cohort of patients with breast cancer before and during the pandemic.

PATIENTS AND METHODS

Twenty-three characteristics were retrospectively analyzed for associations with pre-radiotherapy sleep disorders in 338 patients. Moreover, 163 patients presenting before and 175 patients presenting during the COVID-19 pandemic were compared for sleep disorders.

RESULTS

Sleep disorders were significantly associated with age ≤60 years (p=0.006); high distress score (p<0.0001); more emotional (p<0.0001), physical (p<0.0001) or practical (p<0.0001) problems; psycho-oncological need (p<0.0001); invasive cancer (p=0.003); chemotherapy (p<0.001); and hormonal therapy (p=0.006). Sleep disorders were similarly common in both groups (prior to vs. during the pandemic: 40% vs. 45%, p=0.38).

CONCLUSION

Although additional significant risk factors for sleep disorders were identified, the COVID-19 pandemic appeared to have no significant impact on sleep disorders in patients scheduled for irradiation of breast cancer.

Effect of qigong for sleep disturbance-related symptom clusters in cancer: a systematic review and meta-analysis

OBJECTIVES

To examine the effects of qigong interventions on sleep disturbance-related symptom clusters for cancer patients and to explore the possible mediating role of fatigue and depression in affecting sleep.

METHODS

In this systematic review and meta-analysis, a systematic search was conducted through October 2020 by searching multiple English and Chinese databases. Inclusion was limited to randomized controlled trials that measured the effect of qigong on sleep and fatigue/depressive symptoms in cancer patients. Eleven studies involving 907 cancer patients were included in the systematic review, whereas the meta-analysis included ten studies with 851 cancer patients.

RESULTS

The most commonly investigated form of qigong was Taichi, and the intervention length ranged from 10 days to 6 months. All studies employed self-reported measurements. Overall, qigong significantly improved sleep (SMD = -1.28, 95% CI: -2.01, -0.55) and fatigue (SMD = -0.89, 95% CI: -1.59, -0.19) in cancer patients post-intervention, but not depressive symptoms (SMD = -0.69, 95% CI: -1.81, 0.42). Notably, the benefits on sleep and fatigue became non-significant after 3 months. Qigong's effect on sleep was significantly mediated by its effect on fatigue (β = 1.27, SE = 0.24, p = 0.002), but not depressive symptoms (β = 0.53, SE = 0.26, p = 0.106).

CONCLUSIONS

Qigong can be recommended for improving sleep disturbance-fatigue symptom clusters in the cancer population, while qigong's benefit on sleep is likely based on its effect on reducing fatigue. Future qigong studies should adopt more rigorous design and employ strategies to maintain longevity of intervention benefits.

New and persistent controlled substance use among patients undergoing mastectomy and reconstructive surgery

PURPOSE

Prolonged use of controlled substances can place patients at increased risk of dependence and complications. Women who have mastectomy and reconstructive surgery (M + R) may be vulnerable to becoming new persistent users (NPUs) of opioid and sedative-hypnotic medications.

METHODS

Using the MarketScan health-care claims database, we identified opioid- and sedative-hypnotic-naïve women who had M + R from 2008 to 2017. Women who filled ≥ 1 peri-operative prescription and ≥ 2 post-operative prescriptions within one year after surgery were classified as NPUs. Univariate and multivariable logistic regression analyses were used to estimate rates of new persistent use and predictive factors. Risk summary scores were created based on the sum of associated factors.

RESULTS

We evaluated 23,025 opioid-naïve women and 25,046 sedative-hypnotic-naïve women. We found that 17,174 opioid-naïve women filled a peri-operative opioid prescription, and of those, 2962 (17.2%) became opioid NPUs post-operatively. Additionally, 9426 sedative-hypnotic-naïve women filled a peri-operative sedative-hypnotic prescription, and of those, 1612 (17.1%) became sedative-hypnotic NPUs. Development of new persistent sedative-hypnotic use was associated with age ≤ 49 [OR 1.77 (95% CI 1.40-2.24)] and age 50-64 [1.60 (1.27-2.03)] compared to age ≥ 65; Medicaid insurance [2.34 (1.40-3.90)]; southern residence [1.42 (1.22-1.64)]; breast cancer diagnosis [2.24 (1.28-3.91)]; and chemotherapy [2.17 (1.94-2.42)]. Risk of NPU increased with higher risk score. Women with ≥ 3 of these risk factors were three times more likely to become sedative-hypnotic NPUs than patients with 0 or 1 factors [2.94 (2.51-3.43)]. Comparable findings were seen regarding new persistent opioid use.

CONCLUSION

Women who have M + R are at risk of developing both new persistent opioid and new persistent sedative-hypnotic use. A patient's risk of becoming an NPU increases as their number of risk factors increases. Non-pharmacologic strategies are needed to manage pain and anxiety following cancer-related surgery.

The characteristics and related factors of insomnia among postoperative patients with gastric cancer: a cross-sectional survey

Purpose

This study aims to explore the characteristics and related factors of insomnia of patients after operation for gastric cancer.

Methods

A cross-sectional survey was carried out and finally 115 patients with insomnia after operation for gastric cancer were included. The general information, gastric cancer-related information, sleep quality, and other symptoms were investigated.

Results

① The Pittsburgh sleep quality index score of most insomnia patients after gastric cancer surgery was 11-15 points, and the sleep quality rating was “poor”. ② The sleep quality of patients with insomnia after surgery for gastric cancer is related to the number of chemotherapy cycles, fatigue, and depression. ③ The probability of reduced sleep quality with the number of chemotherapy cycles >6 is 3.640 times that of ≤6. The probability of reduced sleep quality during moderate to severe fatigue was 4.390 times that of patients with no or mild fatigue.

Conclusion

Attention to related factors may be associated with improvement of sleep quality in patients with gastric cancer after surgery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00520-021-06295-6.

Electroacupuncture Plus Auricular Acupressure for Chemotherapy-Associated Insomnia in Breast Cancer Patients: A Pilot Randomized Controlled Trial

Objective:

Chemotherapy-associated insomnia is a highly prevalent complaint in breast cancer patients. This study was undertaken to evaluate the safety, feasibility, and preliminary effectiveness of electroacupuncture plus auricular acupressure for chemotherapy-associated insomnia in patients with breast cancer.

Materials and Methods:

In this randomized, wait-list controlled trial, thirty breast cancer patients under or post chemotherapy with insomnia were randomly allocated to the acupuncture or wait-list control group. Participants in acupuncture group received electroacupuncture plus auricular acupressure treatment twice weekly for 6 weeks. Participants in wait-list group received the same regimen of treatment after 6-week of waiting period. Insomnia Severity Index (ISI) served as the primary outcome measurement. Secondary outcomes were sleep parameters recorded with sleep diary and actiwatch, as well as the scores of Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety and Depression Scale (HADS), and Functional Assessment of Cancer Therapy-Breast Cancer (FACT-B).

Results:

Twenty-eight participants completed study (13 in the acupuncture group vs 15 in the wait-list control group). At week-6 post-intervention, ISI score change from baseline showed significant between-group difference favoring acupuncture group of −2.9 points (95% CI: −5.2 to −0.6, P = .014). The acupuncture group showed greater improvements in the total sleep time recorded by sleep diary (P = .026), scores of PSQI (P = .012), HADS-depression (P = .020), and FACT-B (P < .001) compared with the control group. Improvements were maintained at week-10 and week-14 follow-ups.

Conclusions:

Acupuncture is safe, feasible, and effective for chemotherapy-associated insomnia in breast cancer patients under or post chemotherapy. A larger sample size randomized clinical trial is warranted to confirm the present findings.

Clinical Trial Registration:

NCT03762694.

Sleep-Wake Disturbances in Oncology

Sleep-wake disturbances are common in patients with cancer. Despite the high prevalence of altered sleep patterns in oncology settings, there remains a gap in consistent assessment of sleep, leading to an underrecognized and undertreated condition. Provider failure in addressing sleep-wake disturbances can result in chronic issues with insomnia and has a negative impact on quality of life and cancer survivorship. Often sleep-wake disturbances present in symptom "clusters" including, anxiety, depression, and fatigue, which adds to the complexity of managing sleep disorders in oncology. Aggressive management strategies for managing underlying symptom burden from disease or medications effects is a priority.

A novel approach to management of sleep-associated problems in patients with breast cancer (MOSAIC) during chemotherapy : A pilot study

STUDY OBJECTIVES

This pilot randomized controlled trial (RCT) was conducted to assess the preliminary effects of Brief Behavioral Therapy for Cancer-Related Insomnia (BBT-CI) delivered by trained research staff in comparison to a sleep hygiene pamphlet control and to assess moderators of treatment effect in patients with breast cancer undergoing chemotherapy.

METHODS

Of 74 participants recruited, 37 were randomized to BBT-CI and 37 were randomized to the control condition. Trained staff members delivered the intervention during chemotherapy treatments to reduce patients' burden. Insomnia was assessed with the Insomnia Severity Index (ISI), anxiety was assessed with the Spielberger State-Trait Anxiety Inventory, symptom burden was assessed with the Symptom Inventory (SI), and study staff recorded previous treatments and surgeries received by patients.

RESULTS

Patients randomized to BBT-CI showed significantly greater improvements in their ISI scores compared to the sleep hygiene group. Additionally, several treatment moderators were identified. The effect of BBT-CI was greater among individuals with lower baseline state-trait anxiety, with previous surgery for cancer, and with higher baseline somatic symptom severity.

CONCLUSIONS

BBT-CI shows preliminary efficacy compared to the sleep hygiene handout on insomnia in cancer patients undergoing chemotherapy. A large-phase III RCT needs to be conducted to replicate the preliminary findings.

Sleep Disorders and Psychological Profile in Oral Cancer Survivors: A Case-Control Clinical Study

Simple Summary

Sleep disorders have been increasingly investigated in several medical illnesses as their presence may affect patients’ quality of life. However, the research examining sleep disorders in oral cancer is relatively weak. Indeed, the majority of the available studies present a cross-sectional or retrospective designs. Moreover, very few of them have evaluated quality of sleep in oral cancer survivors (OC survivors). We aimed to carry out a case-control study with the purpose to investigate sleep disorders and mood impairment in 50 OC survivors. Our research has shown that quality of sleep is significantly affected in OC survivors compared to a healthy population and that OC survivors suffers from higher levels of anxiety and depression. Our results may suggest that an appropriate assessment of quality of sleep and psychological profile should be performed in OC survivors as a prompt treatment for both sleep and mood disorders is crucial for the overall improvement of patients’ quality of life.

Abstract

Quality of sleep (QoS) and mood may impair oral cancer survivors’ wellbeing, however few evidences are currently available. Therefore, we aimed to assess the prevalence of sleep disorders, anxiety and depression among five-year oral cancer survivors (OC survivors). 50 OC survivors were compared with 50 healthy subjects matched for age and sex. The Pittsburgh Sleep Quality Index (PSQI), the Epworth Sleepiness Scale (ESS), the Hamilton Rating Scales for Depression and Anxiety (HAM-D, HAM-A), the Numeric Rating Scale (NRS), the Total Pain Rating Index (T-PRI) were administered. The global score of the PSQI, ESS, HAM-A, HAM-D, NRS, T-PRI, was statistically higher in the OC survivors than the controls (p-value: <0.001). QoS of OC survivors was significantly impaired, especially with regard to some PSQI sub-items as the subjective sleep quality, sleep latency and daytime dysfunction (p-value: 0.001, 0.029, 0.004). Moreover, poor QoS was negatively correlated with years of education (p-value: 0.042 *) and positively correlated with alcohol consumption (p-value: 0.049 *) and with the use of systemic medications (p-value: 0.044 *). Sleep disorders and mood disorders are common comorbidities in OC survivors; therefore, early assessment and management before, during and after treatment should be performed in order to improve the quality of life of OC survivors.

Palliative Care Nurse Perceptions of Nonpharmacological Sleep-Promoting Interventions

Poor quality of sleep is common among those with advanced serious illness. Several interventions have been demonstrated to improve sleep; however, the extent to which these are used is unknown. This study describes nurses' perceptions of 36 nonpharmacological sleep-promoting interventions as well as facilitators and barriers to implementing nonpharmacological interventions. A descriptive survey design was used to collect data via an online, anonymous survey from nurses throughout the United States that included demographic items and open-ended questions (barriers and facilitators). The 108 respondents were nurses working in either a hospital (33.3%) or home care/outpatient (54.6%) setting. Among 36 interventions presented, a mean (SD) total score of feasible interventions per respondent was 27.1 (6.5). There were no significant differences in the mean total feasibility score due to practice site, nurse type, or years of experience. Most thought individual belief in the efficacy of the nonpharmacological intervention was an important facilitator whereas perceived lack of value and institutional support were the major barriers. There was an overall appreciation and positive perception of nonpharmacological, sleep-promoting interventions by palliative care nurses. Increasing use will depend on overcoming barriers by identification of specific patient/caregiver and institutional factors in each setting or patient population.

Night Work and Breast Cancer Risk in Nurses: Multifactorial Risk Analysis

Night work has been highlighted by the International Agency for Research on Cancer (IARC) as a likely carcinogenic factor for humans, associated with breast cancer and professions that require continuity of work. Knowing the impact that short and long-term night work has on the nurses' collective seems a priority, therefore, this study aims to analyse the relationship between night work and the development of breast cancer risk factors in nurses. For this, a cross-sectional study through an online questionnaire on breast cancer risk variables and working life was designed. The study was conducted in Spain and the sample consisted of 966 nurses, of whom 502 were healthy participants and 56 were breast cancer patients. These two groups were compared in the analyses. A descriptive analysis was performed, and the relationship was tested using χ2 independence test and OR calculation. The CHAID (Chi Square Automatic Interaction Detection) data mining method allowed for the creation of a segmentation tree for the main risk variables. The most significant risk variables related to working life have been the number of years worked, nights worked throughout life, and years working more than 3 nights per month. Exceeding 16 years of work has been significant for women and men. When the time worked is less than 16 years, the number of cases increases if there is a family history of cancer and if there have been more than 500 nights of work. High-intensity night work seems more harmful at an early age. The accumulation of years and nights worked increase the risk of breast cancer when factors such as sleep disturbance, physical stress, or family responsibilities come together.

Hyperarousal and Insomnia in Survivors of Cancer

BACKGROUND

Cancer survivors are prone to insomnia due to the physical and psychological sequelae of cancer and treatment. Individuals with insomnia may present symptoms of hyperarousal. Cancer survivors with insomnia and trait hyperarousal may require different clinical treatments than patients with insomnia without trait hyperarousal. To our knowledge, no study has examined these factors previously. This study examined the relation between insomnia and trait hyperarousal in cancer survivors.

METHODS

The sample included 160 individuals with previous cancer diagnoses who met DSM-5 criteria for insomnia disorder. Measures were collected with cross-sectional batteries of questionnaires, including the Insomnia Severity Index (ISI) and Hyperarousal Scale (HAS). This study is based on baseline data collected in a randomized clinical trial comparing CBT-I to acupuncture for cancer survivors with insomnia (Garland, Gehrman, Barg, Xie, & Mao, 2016).

RESULTS

Hyperarousal was positively associated with insomnia (ISI total score) in bivariate correlations (r = .350, p < .01) and linear regressions (F = 22.06, p < .001). In bivariate correlations, hyperarousal was related to perceptions about the consequences of disturbed sleep rather than reported sleep patterns. For example, hyperarousal was positively related to reported satisfaction (r = .159, p < .05) and worry about sleep (r = .415, p < .01), but not to falling asleep, staying asleep, or awakening too early. In regressions, younger age, insomnia duration, and worry about sleep were uniquely associated with hyperarousal when adjusting for insomnia (B = 0.200, B = 0.177, B = -0.182, p < .05).

CONCLUSIONS

Hyperarousal is associated with psychological appraisal of insomnia rather than reported sleep pattern. Younger age and longer duration of insomnia are associated with trait hyperarousal. These findings suggest targeting trait hyperarousal with amplified psychological treatment may lead to more personalized, effective treatment for insomnia.

Multi-stakeholder perspectives on managing insomnia in cancer survivors: recommendations to reduce barriers and translate patient-centered research into practice

PURPOSE

Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions.

METHODS

Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that may influence dissemination and implementation.

RESULTS

Multidisciplinary and stakeholder workshop participants (N = 51) identified barriers and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g., knowledge, time, cost), clinician (e.g., education, time, capacity), institutional (e.g., space, insurance reimbursement, referrals), and societal (e.g., lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology.

CONCLUSION

Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care.

IMPLICATIONS FOR CANCER SURVIVORS

Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.