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Pilehvari A, Recklitis CJ, Zhou ES, You W. A retrospective cost-effectiveness analysis of different cognitive-behavioral therapy for insomnia intervention delivery approaches in adult cancer survivors. Psychooncology 2024; 33:e6327. [PMID: 38497829 DOI: 10.1002/pon.6327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND Cognitive-behavioral therapy for insomnia (CBT-I) is considered the gold standard treatment for insomnia. Prior trials have delivered CBT-I across a range of treatment sessions. Understanding the economics of varying treatment approaches is essential for future implementation considerations. METHODS We conducted a retrospective cost-effectiveness analysis from the provider's perspective, comparing the implementation of a three-session CBT-I program for cancer survivors (CBT-I-CS) versus a stepped care treatment approach consisting of an initial single sleep education session followed by CBT-I-CS if elevated insomnia symptoms persisted. The effectiveness measure used was the percentage of participants whose insomnia had remitted by the end of each program. RESULTS Stepped care delivery was more effective than CBT-I-CS alone, resulting in 35.4% more remitted patients by the end of the overall program. For a $480 willingness to pay threshold per percentage of remitted patients, stepped care CBT-I-CS reached a 98% probability of being cost-effective, while CBT-I-CS alone had only a 2% probability. Larger group sessions in the first step of a stepped care delivery model resulted in more favorable cost-effectiveness. CONCLUSIONS A stepped care delivery model may be a more cost-effective approach if it can be implemented efficiently. These findings inform policies aimed at improving cancer survivors' access to much-needed insomnia treatment in settings where financial resources for CBT-I may be limited, and be an important barrier to treatment dissemination. CLINICAL TRIAL REGISTRATION These analyses were not registered.
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Affiliation(s)
- Asal Pilehvari
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
- Comprehensive Cancer Center, University of Virginia, Charlottesville, Virginia, USA
| | | | - Eric S Zhou
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
- Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Wen You
- Department of Public Health Sciences, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
- Comprehensive Cancer Center, University of Virginia, Charlottesville, Virginia, USA
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2
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Li R, Ma Y, Arditte Hall KA, Johnson C, Philpotts LL, Perez GK, Park ER, Hall DL. Representation of race and ethnicity among cancer survivors in trials of cognitive behavioral therapy for insomnia (CBT-I): A systematic review. Support Care Cancer 2023; 32:23. [PMID: 38095732 PMCID: PMC11346510 DOI: 10.1007/s00520-023-08207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/24/2023] [Indexed: 12/18/2023]
Abstract
PURPOSE For cancer survivors, insomnia is highly prevalent and debilitating. Although cognitive behavioral therapy for insomnia (CBT-I) is recognized as a gold standard treatment, it is unclear whether benefits of treatment generalize to racial and ethnic minorities in the USA. This systematic review characterizes the representation of racial and ethnic diversity among cancer survivors in CBT-I clinical trials and provides recommendations for research in sleep/cancer survivorship. METHODS Literature searches were conducted in five electronic databases (PubMed, Cochrane Library via Ovid, PsycINFO via Ovid, Embase, Web of Science Core Collection) using concepts of CBT, insomnia, and cancer survivors. Information about CBT-I intervention details, sample racial demographics, and whether authors explicitly analyzed race and ethnicity were recorded. RESULTS A total of 1673 citations were retrieved, and 967 citations were uploaded to Covidence. Of these, 135 articles went through full-text review and 13 studies were included. Race and ethnicity were reported in 11/13 trials (84.6%). Of those reporting race and ethnicity, 8/11 (72.7%) trials were comprised of samples that were ≥ 85% non-Hispanic White. Among the trials that explicitly analyzed race and ethnicity, CBT-I was more effective among cancer survivors who were White and highly educated, and non-White cancer survivors were less likely to have private insurance and ability to participate in clinical trials. CONCLUSION Non-Hispanic White cancer survivors are overrepresented in CBT-I trials, the best available treatment for insomnia. Underrepresentation of racial and ethnic minorities likely contributes to barriers in access and uptake. Recommendations include implementing sustained efforts to expand diversity in CBT-I clinical trials for cancer survivors.
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Affiliation(s)
- Raissa Li
- Health Promotion and Resiliency Intervention Research Center, Massachusetts General Hospital, 100 Cambridge St., 16th Floor, Boston, MA, USA
- Tufts University School of Medicine, Medford, MA, USA
| | - Yan Ma
- Harvard Medical School, Boston, MA, USA
- Division of Preventive Medicine, Osher Center for Integrative Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Lisa L Philpotts
- Infection Control Unit, Massachusetts General Hospital, Boston, MA, USA
| | - Giselle K Perez
- Health Promotion and Resiliency Intervention Research Center, Massachusetts General Hospital, 100 Cambridge St., 16th Floor, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Elyse R Park
- Health Promotion and Resiliency Intervention Research Center, Massachusetts General Hospital, 100 Cambridge St., 16th Floor, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Daniel L Hall
- Health Promotion and Resiliency Intervention Research Center, Massachusetts General Hospital, 100 Cambridge St., 16th Floor, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
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3
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Vaughan E, Ftanou M, Lewin J, Murnane A, Berger I, Wiley JF, Hickey M, Bullen D, Jefford M, Goldin J, Stonehouse J, Thompson K. AYA 'Can-Sleep' programme: protocol for a stepped-care, cognitive behavioural therapy-based approach to the management of sleep difficulties in adolescents and young adults with cancer. Pilot Feasibility Stud 2022; 8:159. [PMID: 35902975 PMCID: PMC9331489 DOI: 10.1186/s40814-022-01128-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 07/15/2022] [Indexed: 11/27/2022] Open
Abstract
Background Sleep problems are reported in up to 50% of adolescents and young adults (AYA) with cancer. Cognitive behavioural therapy for insomnia (CBTi) is considered the gold-standard treatment. In the AYA population, CBTi is associated with improvements in insomnia, daytime sleepiness, fatigue and quality of life. In adults, stepped-care interventions can improve accessibility to CBTi. This study aims to evaluate the acceptability and feasibility of a stepped-care CBTi programme in AYA with cancer. Methods and analysis AYA (target N = 80) aged 16–25 with a diagnosis of cancer will be screened using the Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS). When sleep difficulties are identified by the ISI and/or ESS, they will be screened for obstructive sleep apnoea and restless leg syndrome and referred to a sleep service if indicated. The remainder with sleep difficulties will be offered a stepped-care sleep programme including CBT self-management and coaching (first step). Participants will then be rescreened at 5 weeks, and those with ongoing sleep difficulties will be offered individualised CBT (second step). Recruitment and retention rates, adherence to intervention and time taken to deliver screening and intervention will be collected to assess the feasibility of the programme. AYA and clinicians will complete evaluation surveys to assess the acceptability of the AYA Can-Sleep programme. Discussion We seek to contribute to the evidence base regarding screening and treatment of sleep difficulties in the AYA population by implementing the AYA Can-Sleep programme and determining its feasibility and acceptability as an approach to care in an Adolescent & Young Adult Cancer Service.
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Affiliation(s)
- Emma Vaughan
- Psychosocial Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Maria Ftanou
- Psychosocial Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Jeremy Lewin
- ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Andrew Murnane
- ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Ilana Berger
- ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Joshua F Wiley
- Behavioural Medicine Unit, Monash University, Melbourne, Victoria, Australia
| | - Martha Hickey
- Women's Gynaecology Research Centre, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - Dani Bullen
- Psychosocial Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Michael Jefford
- University of Melbourne, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Australian Cancer Survivorship Centre, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Health Services Research & Implementation Science, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Jeremy Goldin
- Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jeremy Stonehouse
- Respiratory Medicine and Sleep Disorders, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kate Thompson
- ONTrac at Peter Mac Victorian Adolescent and Young Adult Cancer Service, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia. .,University of Melbourne, Melbourne, Victoria, Australia.
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4
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Hall DL, Arditte Hall KA, Gorman MJ, Comander A, Goldstein MR, Cunningham TJ, Wieman S, Mizrach HR, Juhel BC, Li R, Markowitz A, Grandner M, Park ER. The Survivorship Sleep Program (SSP): A synchronous, virtual cognitive behavioral therapy for insomnia pilot program among cancer survivors. Cancer 2021; 128:1532-1544. [PMID: 34914845 DOI: 10.1002/cncr.34066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/28/2021] [Accepted: 11/13/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND For cancer survivors, insomnia is prevalent, distressing, and persists for years if unmanaged. Cognitive behavioral therapy for insomnia (CBT-I) is an effective treatment yet can be difficult to access and may require modification to address survivorship-specific barriers to sleep. In this 2-phase study, the authors adapted and assessed the feasibility, acceptability, and preliminary effects of synchronous, virtual CBT-I adapted for cancer survivors (the Survivorship Sleep Program [SSP]). METHODS From April to August 2020, cancer survivors with insomnia (N = 10) were interviewed to refine SSP content and delivery. From October 2020 to March 2021, 40 survivors were recruited for a randomized controlled trial comparing 4 weekly SSP sessions with enhanced usual care (EUC) (CBT-I referral plus a sleep hygiene handout). Feasibility and acceptability were assessed by enrollment, retention, attendance, fidelity, survey ratings, and exit interviews. Insomnia severity (secondary outcome), sleep quality, sleep diaries, and fatigue were assessed at baseline, postintervention, and at 1-month follow-up using linear mixed models. RESULTS The SSP included targeted content and clinician-led, virtual delivery to enhance patient centeredness and access. Benchmarks were met for enrollment (56% enrolled/eligible), retention (SSP, 90%; EUC, 95%), attendance (100%), and fidelity (95%). Compared with EUC, the SSP resulted in large, clinically significant improvements in insomnia severity (Cohen d = 1.19) that were sustained at 1-month follow-up (Cohen d = 1.27). Improvements were observed for all other sleep metrics except sleep diary total sleep time and fatigue. CONCLUSIONS Synchronous, virtually delivered CBT-I targeted to cancer survivors is feasible, acceptable, and seems to be efficacious for reducing insomnia severity. Further testing in larger and more diverse samples is warranted.
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Affiliation(s)
- Daniel L Hall
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Kimberly A Arditte Hall
- Department of Psychology and Philosophy, Framingham State University, Framingham, Massachusetts
| | - Mark J Gorman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Amy Comander
- Harvard Medical School, Boston, Massachusetts.,Massachusetts General Hospital Cancer Center, Boston, Massachusetts
| | - Michael R Goldstein
- Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Tony J Cunningham
- Harvard Medical School, Boston, Massachusetts.,Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Psychology and Neuroscience, Boston College, Chestnut Hill, Massachusetts
| | - Sarah Wieman
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Department of Psychology, Suffolk University, Boston, Massachusetts
| | - Helen R Mizrach
- Harvard Medical School, Boston, Massachusetts.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Brooke C Juhel
- Harvard Medical School, Boston, Massachusetts.,Department of Radiation Oncology, Massachusetts General Hospital, Boston, Massachusetts
| | - Raissa Li
- Harvard Medical School, Boston, Massachusetts.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Alexandros Markowitz
- Harvard Medical School, Boston, Massachusetts.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael Grandner
- Department of Psychiatry, The University of Arizona, Tucson, Arizona
| | - Elyse R Park
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts.,Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
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5
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Arem H, Scott R, Greenberg D, Kaltman R, Lieberman D, Lewin D. Assessing Breast Cancer Survivors' Perceptions of Using Voice-Activated Technology to Address Insomnia: Feasibility Study Featuring Focus Groups and In-Depth Interviews. JMIR Cancer 2020; 6:e15859. [PMID: 32348274 PMCID: PMC7284406 DOI: 10.2196/15859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/06/2020] [Accepted: 03/09/2020] [Indexed: 12/16/2022] Open
Abstract
Background Breast cancer survivors (BCSs) are a growing population with a higher prevalence of insomnia than women of the same age without a history of cancer. Cognitive behavioral therapy for insomnia (CBT-I) has been shown to be effective in this population, but it is not widely available to those who need it. Objective This study aimed to better understand BCSs’ experiences with insomnia and to explore the feasibility and acceptability of delivering CBT-I using a virtual assistant (Amazon Alexa). Methods We first conducted a formative phase with 2 focus groups and 3 in-depth interviews to understand BCSs’ perceptions of insomnia as well as their interest in and comfort with using a virtual assistant to learn about CBT-I. We then developed a prototype incorporating participant preferences and CBT-I components and demonstrated it in group and individual settings to BCSs to evaluate acceptability, interest, perceived feasibility, educational potential, and usability of the prototype. We also collected open-ended feedback on the content and used frequencies to describe the quantitative data. Results We recruited 11 BCSs with insomnia in the formative phase and 14 BCSs in the prototype demonstration. In formative work, anxiety, fear, and hot flashes were identified as causes of insomnia. After prototype demonstration, nearly 79% (11/14) of participants reported an interest in and perceived feasibility of using the virtual assistant to record sleep patterns. Approximately two-thirds of the participants thought lifestyle modification (9/14, 64%) and sleep restriction (9/14, 64%) would be feasible and were interested in this feature of the program (10/14, 71% and 9/14, 64%, respectively). Relaxation exercises were rated as interesting and feasible using the virtual assistant by 71% (10/14) of the participants. Usability was rated as better than average, and all women reported that they would recommend the program to friends and family. Conclusions This virtual assistant prototype delivering CBT-I components by using a smart speaker was rated as feasible and acceptable, suggesting that this prototype should be fully developed and tested for efficacy in the BCS population. If efficacy is shown in this population, the prototype should also be adapted for other high-risk populations.
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Affiliation(s)
- Hannah Arem
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, United States.,George Washington Cancer Center, Washington, DC, United States
| | - Remle Scott
- Department of Epidemiology, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
| | | | - Rebecca Kaltman
- Division of Hematology and Oncology, Medical Faculty Associates, George Washington University, Washington, DC, United States
| | - Daniel Lieberman
- Department of Psychiatry and Behavioral Sciences, Medical Faculty Associates, George Washington University, Washington, DC, United States
| | - Daniel Lewin
- Children's National Health System, Washington, DC, United States
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6
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Sheng JY, Visvanathan K, Thorner E, Wolff AC. Breast cancer survivorship care beyond local and systemic therapy. Breast 2020; 48 Suppl 1:S103-S109. [PMID: 31839149 DOI: 10.1016/s0960-9776(19)31135-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Despite persistent inequities in access to care and treatments, advances in combined modality care have led to a steady improvement in outcomes for breast cancer patients across the globe. When estimating the magnitude of clinical benefit of therapies, providers and patients must contend with a multitude of factors that impact treatment decisions and can have long-term effects on quality of life and survival. These include commonly described early toxicities, like aromatase inhibitor-associated musculoskeletal syndrome and neuropathy. But longer-term comorbidities often observed among cancer survivors including weight gain, obesity, infertility, psychological distress, sexual dysfunction, second cancers, bone loss, and body image issues can have lasting effects on quality of life. Equally important, system-level factors such as access to care and resource allocation can have a systemic impact on survival and on the quality of survivorship. Financial toxicity including underemployment can have a lasting impact on patients and caregivers. The resulting disparities in access to treatment can help explain much of the observed variability in outcomes, even within high-income countries like the US. This article revisits some of secondary effects from therapies discussed in a prior 2015 review article, along with other impediments to the optimal delivery of breast cancer care that can affect patients anywhere.
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Affiliation(s)
- Jennifer Y Sheng
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Kala Visvanathan
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Elissa Thorner
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA
| | - Antonio C Wolff
- The Johns Hopkins University School of Medicine, The Johns Hopkins Bloomberg School of Public Health, and The Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD, USA.
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7
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Dean GE, Weiss C, Jungquist CR, Klimpt ML, Alameri R, Ziegler PA, Steinbrenner LM, Dexter EU, Dhillon SS, Lucke JF, Dickerson SS. Nurse-Delivered Brief Behavioral Treatment for Insomnia in Lung Cancer Survivors: A Pilot RCT. Behav Sleep Med 2020; 18:774-786. [PMID: 31672070 PMCID: PMC7190424 DOI: 10.1080/15402002.2019.1685523] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Objective/Background: Insomnia occurs in 50 to 80% of lung cancer survivors. Cognitive behavioral therapy is the standard treatment for insomnia (CBTI); however, treatment length and lack of psychologists trained in CBTI limits access. Brief Behavioral Treatment for Insomnia (BBTI), a nurse-delivered modified CBTI, is proposed. This feasibility pilot study sought to compare the BBTI intervention to attention control Healthy Eating Program (HEP) for insomnia in lung cancer survivors. Participants: The participants comprised adults, 21 years of age or older with insomnia and stage I/II non-small cell lung cancer, more than 6 weeks from surgery and living in Western NY. Methods: Participants (n = 40) were randomly assigned to an experimental (BBTI) or attention control condition (Healthy Eating Program). Thirty participants completed the study. Results: Participants were 66 years of age (± 7.6; range 53-82), 40% (n = 16) male, 87.5% (n = 35) Caucasian, 50% (n = 20) married, BMI 27.7 (± 5.8), and 12% (n = 5) never smokers. Baseline sleep diary sleep efficiency, ISI and other baseline covariates were balanced between the groups. Sleep efficiency improved ≥85% in BBTI group (p = .02), but not in HEP control group (p = 1.00). Mean ISI for BBTI and attention control were 6.40 ± 4.98 and 14.10 ± 4.48 (p = .001) respectively. In addition, BBTI group mean total FACT-L score improved by 6.66 points from baseline while HEP group score worsened (p = .049). Conclusions: BBTI is a practical, evidence-based, clinically relevant intervention that improved sleep and quality of life in lung cancer survivors with insomnia. Additional research to evaluate efficacy, duration, and implementation strategies are essential.
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Affiliation(s)
- Grace E. Dean
- University at Buffalo, State University of New York, School
of Nursing, Buffalo, NY
| | - Carleara Weiss
- University at Buffalo, State University of New York, School
of Nursing, Buffalo, NY
| | - Carla R. Jungquist
- University at Buffalo, State University of New York, School
of Nursing, Buffalo, NY
| | - Michelle L. Klimpt
- University at Buffalo, State University of New York, School
of Nursing, Buffalo, NY
| | - Rana Alameri
- Department of Fundamental Nursing, College Nursing, Imam
Abdulrahman Bin Faisal University, Saudi Arabia
| | | | - Lynn M. Steinbrenner
- Jacobs School of Medicine, Buffalo, NY,VA Western New York Health Systems and Department of
Medicine, Buffalo, NY
| | - Elisabeth U. Dexter
- Jacobs School of Medicine, Buffalo, NY,Thoracic Oncology, Roswell Park Cancer Institute, Buffalo,
NY
| | - Samjot S. Dhillon
- Jacobs School of Medicine, Buffalo, NY,Thoracic Oncology, Roswell Park Cancer Institute, Buffalo,
NY
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8
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Zhou ES, Michaud AL, Recklitis CJ. Developing efficient and effective behavioral treatment for insomnia in cancer survivors: Results of a stepped care trial. Cancer 2019; 126:165-173. [PMID: 31550051 DOI: 10.1002/cncr.32509] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/09/2019] [Accepted: 08/09/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Insomnia is common among cancer survivors. Although behavioral treatments for insomnia are effective, access is limited. Stepped care delivery models may provide insomnia treatment that is more efficient and accessible to cancer survivors. METHODS Fifty-one survivors (mean age, 55 years) with elevated Insomnia Severity Index (ISI) scores (≥12) first participated in Sleep Training Education Program (STEP)-1: a single, sleep education session. Those reporting elevated ISI scores 1 month later were offered STEP-2: a 3-session, group cognitive behavioral treatment for insomnia that has been demonstrated to be efficacious. Participants were considered treatment responders if their ISI score improved by ≥6 points and were considered as having remitted if their posttreatment ISI score was <12. Mood was assessed with the Profile of Mood States-Short Form (POMS-SF). RESULTS Following STEP-1, ISI scores improved (17.1 to 11.2; P < .001), with 45% responding and 41% remitted. Insomnia remission after STEP-1 was associated with lower insomnia severity and shorter duration of sleep problems at baseline. Of the 30 (59%) survivors with unremitted insomnia after STEP-1, 14 (47%) participated in STEP-2. Following STEP-2, ISI scores improved (16.9 to 8.8; P < .001), with 79% responding and 71% remitted. STEP-2 participation was associated with interest in sleep treatment at baseline, but not demographic/health-related variables. Mood improved significantly following both STEP-1 and STEP-2 (P < .001). CONCLUSION A stepped care approach to treating insomnia among cancer survivors has the potential to improve treatment accessibility. A sizable proportion of survivors can benefit from 2 different low-intensity approaches that could be delivered by nonsleep specialists. For individuals who require more intensive care, assessing treatment interest can identify those who are likely to engage.
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Affiliation(s)
- Eric S Zhou
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Alexis L Michaud
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christopher J Recklitis
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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9
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Psychological support for patients with cancer: evidence review and suggestions for future directions. Curr Opin Support Palliat Care 2019; 12:276-292. [PMID: 30074924 DOI: 10.1097/spc.0000000000000360] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Psychological distress and mental health comorbidity are common in cancer. Various therapeutic frameworks have been used for interventions to improve psychological wellbeing and quality of life in cancer patients with mixed results. This article reviews contributions to that literature published since January 2017. RECENT FINDINGS The majority of new psychological intervention research in cancer has used cognitive behavioural therapy (CBT) or mindfulness-based interventions. CBT has been considered a gold-standard intervention and recent evidence justifies continuation of this. Recent reviews call into question the validity of evidence for mindfulness-based interventions. A smaller number of trials using acceptance and commitment therapy, meta-cognitive therapy, dignity therapy and coaching have emerged, and whereas findings are promising, additional fully powered trials are required. Weaker evidence exists for counselling, support-based and narrative therapy interventions. SUMMARY Efficacious, timely and acceptable psychological interventions are a necessary component of comprehensive cancer care. There is some way to go before the evidence conclusively points towards which interventions work for which cancer groups and for which specific outcomes. Methodological limitations must be addressed in future trials; at the forefront remains the need for fully powered, head-to-head comparison trials.
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10
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Yusufov M, Zhou ES, Recklitis CJ. Psychometric properties of the Insomnia Severity Index in cancer survivors. Psychooncology 2019; 28:540-546. [PMID: 30597686 DOI: 10.1002/pon.4973] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/17/2018] [Accepted: 12/26/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Insomnia is commonly associated with cancer treatment. Cancer treatments increase risk for numerous psychological and medical late effects, thus making cancer survivors psychologically and medically vulnerable. Prior research examined psychometric properties of the Insomnia Severity Index (ISI) with various populations, including the French version of the ISI, with participants undergoing active cancer treatment. However, no prior studies examined insomnia exclusively with cancer survivors, using the English version of the ISI. METHODS This study examined internal consistency and factor structure of an English version of the ISI in 100 cancer survivors (Mage = 51.1; SD = 14.92). This final analytic sample was composed of participants from three different insomnia interventions. Survivors ranged from less than 1 year off treatment (17%) to 21+ years off treatment (6%), with most participants off treatment for 1 to 2 years (24%). RESULTS The mean ISI score for the total sample was 16.69 (SD = 4.47), indicating clinical insomnia, with moderate severity. Principal Components Analysis (PCA) indicated two factors (five items loading on Factor I and two items loading on Factor II) and acceptable reliability (α = .73). Item-total correlations ranged from .15 to .63. CONCLUSIONS Findings support the reliability of the ISI in cancer survivors. However, its factor structure warrants additional research with larger samples of cancer survivors. Results suggest inconsistency across participant responses and that ISI items may be functioning differently with this unique population of cancer survivors. Findings indicate that sleep maintenance problems are central to the experience of insomnia in our survivor sample.
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Affiliation(s)
- Miryam Yusufov
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Department of Psychiatry, Boston, MA, USA
| | - Eric S Zhou
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Department of Pediatrics, Boston, MA, USA
| | - Christopher J Recklitis
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Department of Pediatrics, Boston, MA, USA
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11
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Zhou ES, Clark K, Recklitis CJ, Obenchain R, Loscalzo M. Sleepless from the Get Go: Sleep Problems Prior to Initiating Cancer Treatment. Int J Behav Med 2018; 25:502-516. [PMID: 29546585 DOI: 10.1007/s12529-018-9715-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Cancer patients are likely to experience sleep problems. Understanding their perception of sleep problems is important as subjective symptom experience is associated with treatment-seeking behavior. We explored the prevalence of sleep problems and its correlates in a large sample of cancer patients at an important but understudied stage of their cancer journey: prior to initiating treatment. METHODS Cancer patients (5702) (67.5% female; 76.9% White; 23.0% Hispanic), following diagnosis and prior to initiating cancer treatment, completed an electronic screening instrument. Patients across eight different cancer diagnoses (breast, gastrointestinal, gynecological, head and neck, hematological, lung, prostate, urinary) rated their sleep problems on a five-point scale, with those reporting "severe" or "very severe" sleep problems classified as having high sleep problems. RESULTS Overall, 12.5% of patients reported high sleep problems. Across diagnoses, the proportion of patients reporting high sleep problems ranged from 4.3 to 13.8%, with prostate cancer patients least likely and gastrointestinal cancer patients most likely to report high sleep problems. Older age, having a partner, higher education, and higher household income were associated with a lower likelihood of experiencing sleep problems. Being female, Black, Hispanic, and reporting anxiety or depression was associated with an increased likelihood of sleep problems. CONCLUSIONS A sizeable proportion of cancer patients experience significant problems with their sleep before any treatment has occurred. This clinical issue cannot be ignored as treatment is likely to worsen existing sleep problems. Oncology providers should routinely screen for sleep-related problems. Identifying and treating patients for sleep problems during a vulnerable period early in their cancer trajectory should be an essential component of clinical care.
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Affiliation(s)
- Eric S Zhou
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, MA, USA.
- Pediatrics, Harvard Medical School, Boston, MA, USA.
| | - Karen Clark
- Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher J Recklitis
- Perini Family Survivors' Center, Dana-Farber Cancer Institute, Boston, MA, USA
- Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Richard Obenchain
- Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
| | - Matthew Loscalzo
- Supportive Care Medicine, City of Hope National Medical Center, Duarte, CA, USA
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12
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Qiu H, Ren W, Yang Y, Zhu X, Mao G, Mao S, Lin Y, Shen S, Li C, Shi H, Jiang S, He J, Zhao K, Fu Y, Hu X, Gu Y, Wang K, Guo X, He J. Effects of cognitive behavioral therapy for depression on improving insomnia and quality of life in Chinese women with breast cancer: results of a randomized, controlled, multicenter trial. Neuropsychiatr Dis Treat 2018; 14:2665-2673. [PMID: 30349264 PMCID: PMC6188154 DOI: 10.2147/ndt.s171297] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
PURPOSE Cognitive behavioral therapy (CBT) for depression had been found to be effective in reducing depressive and anxiety symptoms in breast cancer survivors. It is not known whether CBT for depression would also improve insomnia and quality of life (QOL). The aim of this study was to investigate whether CBT for depression would improve insomnia and QOL in a randomized controlled multicenter trial. PATIENTS AND METHODS In this study, breast cancer survivors (n=392) were randomly allocated to the following three groups: CBT (n=98), self-care management (SCM, n=98), and usual care (UC, n=196) in a ratio of 1:1:2. CBT and SCM received a series of nine sessions for 12 weeks, whereas UC received UC only. Insomnia and QOL were evaluated using Athens Insomnia Scale (AIS) and Functional Assessment of Cancer Therapy-Breast (FACT-B) questionnaire at baseline, 4, 12, and 24 weeks. RESULTS There was a significant intergroup difference in AIS and FACT-B scores (both P<0.01). CBT showed less insomnia problems and better overall QOL compared with those in SCM and UC (both P<0.01). No significant differences were found between SCM and UC in insomnia problems and overall QOL. Moreover, the effects of CBT on insomnia and QOL were maintained during the follow-up period. CONCLUSION CBT for depression can be effective in improving insomnia problems and QOL in the Chinese breast cancer survivors.
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Affiliation(s)
- Huihua Qiu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Wenwei Ren
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Yanjie Yang
- Department of Medical Psychology, Public Health Institute of Harbin Medical University, Harbin, People's Republic of China
| | - Xiongzhao Zhu
- Medical Psychological Institute, Second Xiangya Hospital, Central South University, Changsha, People's Republic of China
| | - Guangyun Mao
- Department of Preventive Medicine, Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Shanping Mao
- Department of Neurology, RenMin Hospital of Wuhan University, Wuhan, People's Republic of China
| | - Yan Lin
- Department of Neurology, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Shanshan Shen
- Department of Geriatrics, Zhejiang Hospital, Hangzhou, People's Republic of China
| | - Changjin Li
- Department of Psychology, Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Hongying Shi
- Department of Preventive Medicine, Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Suo Jiang
- Department of Psychology, Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Jingjing He
- Department of Psychiatry, Tongde Hospital of Zhejiang Province, Hangzhou, People's Republic of China
| | - Ke Zhao
- Department of Psychology, Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Ye Fu
- Yinzhou Hospital Affiliated To Medical School of Ningbo University, Ningbo, People's Republic of China
| | - Xiaoqu Hu
- Department of Oncology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Yingying Gu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China,
| | - Kai Wang
- Department of Psychiatry, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Xiuchan Guo
- Key Laboratory of Laboratory Medicine, School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, People's Republic of
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China, .,Department of Psychology, Wenzhou Medical University, Wenzhou, People's Republic of China,
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13
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Provision of integrated psychosocial services for cancer survivors post-treatment. Lancet Oncol 2017; 18:e39-e50. [PMID: 28049576 DOI: 10.1016/s1470-2045(16)30659-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/03/2016] [Accepted: 10/04/2016] [Indexed: 12/25/2022]
Abstract
Meeting the psychosocial needs of patients with cancer has been recognised as a priority within oncology care for several decades. Many approaches that address these needs have been developed and described; however, until recently much of this work had focused on patients during treatment and end-of-life care. With continued improvement in therapies, the population of cancer survivors who can expect to live for 5 or more years after cancer diagnosis has increased dramatically, as have associated concerns about how to meet their medical, psychosocial, and health behaviour needs after treatment. Guidelines and models for general survivorship care routinely address psychosocial needs, and similar guidelines for psychosocial care of patients with cancer are being extended to address the needs of survivors. In this Series paper, we summarise the existing recommendations for the provision of routine psychosocial care to survivors, as well as the challenges present in providing this care. We make specific recommendations for the integration of psychosocial services into survivorship care.
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14
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Cognitive-Behavioral Therapy for Insomnia in Cancer Patients: An Update of Efficacy Evidence and Areas for Future Research. CURRENT SLEEP MEDICINE REPORTS 2017. [DOI: 10.1007/s40675-017-0067-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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15
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Zhou ES, Partridge AH, Syrjala KL, Michaud AL, Recklitis CJ. Evaluation and treatment of insomnia in adult cancer survivorship programs. J Cancer Surviv 2017; 11:74-79. [PMID: 27495283 PMCID: PMC5865603 DOI: 10.1007/s11764-016-0564-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 07/26/2016] [Indexed: 11/26/2022]
Abstract
PURPOSE Insomnia is commonly experienced by cancer survivors. Chronic insomnia is associated with significant physical and psychosocial consequences if not properly treated. Both the National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN) recommend the evaluation of sleep disturbances and evidence-based treatment of insomnia during routine survivorship care. To better understand current clinical practices, we conducted a survey of major cancer centers across the United States (US). METHODS Adult survivorship programs at the 25 US cancer centers that are both NCI-designated comprehensive cancer centers and NCCN member institutions were surveyed about the evaluation and treatment of insomnia in their hospital. RESULTS All institutions responded to the survey. Thirteen centers (56 %) reported screening <25 % of survivors for sleep disorders, and few clinicians providing survivorship care were well-prepared to conduct a proper sleep evaluation. Insomnia was most commonly treated with sleep hygiene, or pharmacotherapy, rather than cognitive-behavioral therapy. No program reported that >50 % of their survivors were receiving optimal insomnia-related care. A variety of methods to improve insomnia care were endorsed by respondents. CONCLUSIONS There is a clear need to improve the evaluation and treatment of insomnia for cancer survivors at institutions across the country. Cancer centers deemed a number of modalities relevant for improving provider confidence in addressing sleep challenges. IMPLICATIONS FOR CANCER SURVIVORS To improve the quality of insomnia care for survivors, systematic interventions to increase standardized screening for sleep disorders, providing additional sleep medicine training for survivorship clinicians, and optimizing the role of sleep medicine specialists in the oncology setting should be considered.
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Affiliation(s)
- Eric S Zhou
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA.
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Ann H Partridge
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Karen L Syrjala
- Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue N, Seattle, WA, 98109, USA
| | - Alexis L Michaud
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| | - Christopher J Recklitis
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
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