Daytime sleepiness and sleep duration in long-term cancer survivors and non-cancer controls: results from a registry-based survey study

Sleep disturbances among cancer survivors

PURPOSE

We investigated sleep disturbances among cancer survivors compared to similarly aged women without cancer history.

METHODS

We identified 2067 women with a history of cancer other than breast or non-melanoma skin cancer at enrollment in the Sister Study, a US-wide cohort of women with a family history of breast cancer. Cancer survivors were matched with up to 5 cancer-free women (N = 9717) on age at enrollment. An index age (for covariate classification) was defined as the age at cancer diagnosis for survivors and the same age for their matched comparators. Sleep disturbances included duration, sleep medication usage, insomnia symptoms, long sleep-latency onset (≥30 min to fall asleep), frequent night awakenings (waking ≥3/night, ≥ 3 times/week), frequent napping (≥ 3 times/week), and a composite outcome of ≥ 1sleep disturbance. Multivariable linear regression (effect estimate, 95% confidence interval (CI)) and logistic regression (odds ratio, OR, 95% CI) were used for continuous and dichotomous outcomes, respectively.

RESULTS

At enrollment, cancer survivors were on average 13.8 years (range=0, 62) from diagnosis. After adjustment for age at enrollment and depression, diabetes, hypertension, and menopausal status prior to the index age, sleep disturbances were generally not more common among cancer survivors compared to those without cancer. However, among cancer survivors, those > 2 years from diagnosis were more likely to report ≥ 1 sleep disturbance (OR=1.44; 1.07, 1.93) compared to survivors 0-2 years from diagnosis.

CONCLUSION

Addressing sleep disturbances may improve well-being for cancer survivors.

Insomnia among Cancer Patients in the Real World: Optimising Treatments and Tailored Therapies

BACKGROUND

Insomnia is commonly reported by cancer patients. Its multifaceted pathophysiology makes this symptom a complex challenge for the clinician, who should bear in mind the manifold world of causes and consequences of sleep disturbances in these patients and the importance of accurate treatment that should consider the frequent co-prescription of multiple medications. With our work, we aim to provide a tool to better master the treatment of this symptom in cancer patients, considering the gap between clinical and pharmacodynamic knowledge about the efficacy of different molecules and evidence-based prescribing.

METHODS

A narrative review of the studies investigating the pharmacological treatment of insomnia in cancer patients was conducted. Three hundred and seventy-six randomised controlled trials (RCTs), systematic reviews and meta-analyses were identified through PubMed. Only publications that investigated the efficacy of the pharmacological treatment of insomnia symptoms in cancer patient were considered.

RESULTS

Among the 376 publications that were individuated, fifteen studies were eligible for inclusion in the review and were described. Pharmacological treatments were outlined, with a broad look at specific clinical situations.

CONCLUSIONS

The management of insomnia in cancer patients should be personalised, as is already the case for the treatment of pain, taking into account both the pathophysiology and the other medical treatments prescribed to these patients.

Sleep pattern, healthy lifestyle and colorectal cancer incidence

Researchers have identified an association between lifestyle factors and colorectal cancer (CRC) risk. This study examined the relationship between sleep patterns and CRC events. 392,252 individuals were sampled from the UK Biobank. Chronotype, sleep duration, insomnia, snoring, and excessive daytime sleepiness were combined to measure a healthy sleep score. A number of healthy sleep factors were defined, along with factors for healthy lifestyle scores. Using Cox proportional hazards regression, computed hazard ratios (HRs) were used to examine the associations between sleep patterns, healthy lifestyles, and the incidence of CRC. Healthy sleep scores were inversely associated with CRC events. The HRs for CRC were 0.90 (95% CI, 0.88-0.92) and 0.95 (95% CI, 0.92-0.98) for a 1-point healthy sleep score increase among males and females. When analyzing sleep components, sleeping 7-8 h/day, no frequent insomnia, no snoring, and no frequent daytime sleepiness were independently associated with a 9%, 14%, 8%, and 14% lower risk of CRC, respectively, whilst healthy lifestyle scores were inversely associated with CRC incidence across all models. Sleep pattern and lifestyle are significantly correlated with CRC risk. The healthier the subject's lifestyle and sleep pattern, the lower their CRC risk.

Fatigue and brain arousal in patients with major depressive disorder

Fatigue is considered a key symptom of major depressive disorder (MDD), yet the term lacks specificity. It can denote a state of increased sleepiness and lack of drive (i.e., downregulated arousal) as well as a state of high inner tension and inhibition of drive with long sleep onset latencies (i.e., upregulated arousal), the latter typically found in depression. It has been proposed to differentiate fatigue along the dimension of brain arousal. We investigated whether such stratification within a group of MDD patients would reveal a subgroup with distinct clinical features. Using an automatic classification of EEG vigilance stages, an arousal stability score was calculated for 15-min resting EEGs of 102 MDD patients with fatigue. 23.5% of the patients showed signs of hypoarousal with EEG patterns indicating drowsiness or sleep; this hypoaroused subgroup was compared with remaining patients (non-hypoaroused subgroup) concerning self-rated measures of depressive symptoms, sleepiness, and sleep. The hypoaroused subgroup scored higher on the Beck Depression Inventory items "loss of energy" (Z = - 2.13, p = 0.033; ɳ² = 0.044, 90% CI 0.003-0.128) and "concentration difficulty" (Z = - 2.40, p = 0.017; ɳ² = 0.056, 90% CI 0.009-0.139), and reported higher trait and state sleepiness (p < 0.05) as compared to the non-hypoaroused group. The non-hypoaroused subgroup, in contrast, reported more frequently the presence of suicidal ideation (Chi² = 3.81, p = 0.051; ɳ² = 0.037, 90% CI 0.0008-0.126). In this study, we found some evidence that stratifying fatigued MDD patients by arousal may lead to subgroups that are pathophysiologically and clinically more homogeneous. Brain arousal may be a worth while target in clinical research for better understanding the mechanisms underlying suicidal tendencies and to improve treatment response.

Prevalence of Healthy Behaviors among Cancer Survivors in the United States: How Far Have We Come?

BACKGROUND

The 16.9 million cancer survivors in the United States are at increased risk for comorbidities and recurrence. However, this risk may be attenuated by a healthy lifestyle. This study describes health behaviors by cancer history to inform behavior change priorities.

METHODS

We analyzed 2013-2017 data from the National Health Interview Survey. There were 164,692 adults, of whom 12,648 reported a cancer history. We calculated prevalence of smoking, physical activity, alcohol consumption, body mass index (BMI), and sleep duration by cancer history, age, and cancer site. We conducted logistic regression to determine odds of meeting lifestyle recommendations by cancer history.

RESULTS

Overall, those with a cancer history were less likely to report current smoking (14.1% vs. 16.8%) and moderate/heavy drinking (18.8% vs. 21.9%) than those without a cancer history. However, a lower percentage of cancer survivors met physical activity guidelines (14.2% vs. 21.1%) or reported a healthy BMI (31.6% vs. 34.7%) compared with those without a cancer history. Cancer survivors were more likely to report excessive sleep (6.8% vs. 3.6%). In adjusted logistic regression, survivors were more likely to meet recommendations on smoking, physical activity, and BMI but were less likely to meet alcohol recommendations; meeting sleep recommendations did not differ by cancer history.

CONCLUSIONS

While cancer survivors had lower prevalence of smoking and moderate/heavy drinking, they also had lower prevalence of physical activity and healthy BMI, and reported longer sleep duration. Regression analyses suggested survivors only showed poorer behaviors for alcohol.

IMPACT

Targeted health promotion interventions among cancer survivors are needed.

Chemotherapy effect on daytime sleepiness and contributing factors in older adults with cancer

OBJECTIVES

The objective of this study was to determine the prevalence of excessive daytime sleepiness (EDS) among older Iranian patients with cancer and to analyze the effect of chemotherapy treatment on patients' sleep problems. The relationship between sleep disturbances and physical activity, psychological factors, and demographic data, are also explored.

METHODS

This cross-sectional study consisted of interviews with 83 patients, >60 years old with a solid tumor, carried out in Cancer Institute of Iran once prior to receiving chemotherapy and the second time after the first cycles of chemotherapy. Questionnaires consisted of demographic data, Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scales (HADS), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), and Eastern Cooperative Oncology Group performance status (ECOG PS). Medical data were also gathered from hospital records. Logistic regression was used to identify predictors of excessive daytime sleepiness after chemotherapy.

RESULTS

The results showed a significant association between EDS and receiving chemotherapy. 8.1% were initially experiencing EDS which increased to 21.6% after chemotherapy (P-value < .001). Anxiety before chemotherapy and number of regions of recurrence of cancer, if any, were identified as independent predictors of daytime sleepiness.

CONCLUSIONS

As EDS prevalence increases after chemotherapy, and this can affect patients' quality of life and treatment outcomes; caregivers should bear in mind that senior patient with cancer, especially those suffering from anxiety and cancer recurrence, need special attention before starting treatment in order to manage EDS over the course of chemotherapy.

Sleep problems in breast cancer survivors 1-10 years posttreatment

ABSTRACTObjective:Sleep can affect quality of life (QoL) during cancer survivorship, and symptoms related to poor sleep can be exacerbated. We examined the prevalence, severity, and nature of subjective sleep complaints in women surviving stage I-III breast cancer who were 1-10 years posttreatment. We also examined the demographic, medical, physical, and psychosocial correlates of poor sleep in these women in order to identify the subgroups that may be most in need of intervention.

METHOD

A total of 200 patients at a comprehensive cancer center who were 1-10 years posttreatment for primary stage I-III breast cancer with no evidence of disease at the time of enrollment completed a battery of questionnaires on demographics, sleep, physical symptoms, mood, cancer-specific fears, and QoL.

RESULTS

The women had a mean age of 57 years (SD = 10.0), with a mean of 63.3 months (SD = 28.8) of post-cancer treatment. Some 38% of these patients were identified as having poor-quality sleep. Women with poor sleep took longer to fall asleep, had more awakenings, and acquired 2 hours less sleep per night than those with good sleep. They also had a lower QoL, greater severity of pain, more concerns about health and recurrence, and increased vasomotor symptoms (p < 0.05). Daytime sleepiness and depression were found to be not significantly correlated with sleep quality.

SIGNIFICANCE OF RESULTS

Many breast cancer survivors had severe subjective insomnia, and several breast cancer survivor subgroups were identified as having members who might be most in need of sleep-improvement interventions. Addressing physical symptoms (e.g., vasomotor symptoms and pain) and providing education about the behavioral, social, environmental, and medical factors that affect sleep could result in substantial improvement in the life course of breast cancer survivors.

Fatigue with up- vs downregulated brain arousal should not be confused

Fatigue is considered to be an important and frequent factor in motivation problems. However, this term lacks clinical and pathophysiological validity. Semantic precision has to be improved. Lack of drive and tiredness with increased sleepiness as observed in fatigue in the context of inflammatory and immunological processes (hypoaroused fatigue) has to be separated from inhibition of drive and tiredness with prolonged sleep onset latency as observed in major depression (hyperaroused fatigue). Subjective experiences as reported by patients, as well as clinical, behavioral, and neurobiological findings support the validity and importance of this distinction. A practical clinical procedure for how to separate hypo- from hyperaroused fatigue will be proposed.

Symptom burden and quality of life in survivorship: a review of the literature

BACKGROUND

Cancer has a great impact on the well-being of affected persons and their caregivers long into survivorship.

OBJECTIVE

This article reviews the state of science on the survivorship experience of cancer survivors and caregivers, with a focus on symptom burden and quality of life (QOL) after treatment termination.

METHODS

The primary databases utilized included PubMed and CINAHL. Search results were limited to human participants, English language, and publications from 2008 to 2013. The articles retrieved included studies of prostate, breast, colorectal, and gynecologic cancers during adulthood.

RESULTS

As many as a third of cancer survivors experienced symptoms after treatment cessation equivalent to those experienced during treatment. Fatigue, depression or mood disturbance, sleep disruption, pain, and cognitive limitation were commonly reported by survivors across various malignancies; depression, anxiety, and sleep disturbance affected some caregivers. The studies indicated residual symptoms that extend into survivorship have a great impact on QOL and are associated with disability and healthcare utilization. Younger age, lower socioeconomic status, and increased comorbidities are associated with poorer QOL and higher symptom distress in cancer survivors. Younger age and lower income are associated with greater distress and poorer QOL in caregivers.

CONCLUSIONS

Survivors and caregivers struggle with symptom burden and diminished QOL long into survivorship. Longitudinal studies are needed to investigate the persistence and severity of symptom burden over time as well as long-term and late effects of these symptoms.

IMPLICATIONS FOR PRACTICE

Interventions designed to help alleviate symptom burden in those most affected are needed.

Effects of armodafinil and cognitive behavior therapy for insomnia on sleep continuity and daytime sleepiness in cancer survivors

STUDY OBJECTIVES

This study involves the analysis of a secondary outcome of a trial examining whether cognitive behavior therapy for insomnia (CBT-I), a wake-promoting medication (armodafinil), or both results in greater improvement in prospectively assessed sleep continuity and daytime sleepiness than a placebo-alone group among a heterogeneous group of cancer survivors. Whether or not armodafinil alone, and/or when combined with CBT-I, affected adherence with CBT-I was evaluated.

DESIGN

This study is a randomized, placebo-controlled, clinical trial.

SETTING

This study was conducted at two northeastern academic medical centers.

PARTICIPANTS

Eighty-eight cancer survivors with chronic insomnia were recruited between October 2008 and November 2012. Participants were assigned to one of four conditions: 1) CBT-I and placebo (CBT-I+P); 2) CBT-I and armodafinil (CBT-I + A); 2) armodafinil alone (ARM); or 4) placebo alone (PLA).

INTERVENTIONS

CBT-I was delivered in seven weekly individual therapy sessions (three in person, four via telephone). The armodafinil dosage was 50 mg BID.

MEASUREMENTS AND RESULTS

Sleep continuity was measured with daily sleep diaries assessing sleep latency (SL), wake after sleep onset (WASO), and total sleep time (TST). The Epworth Sleepiness Scale (ESS) measured daytime sleepiness. Compared to the PLA group, the CBT-I+P and CBT-I+A groups reported a significant reduction in SL with effect sizes of 0.67 and 0.58, respectively. A significant reduction was observed in WASO in the CBT-I+A group with an effect size of 0.64. An increasing trend of TST was observed in the CBT-I+P, CBT-I+A, and PLA groups, but not in the ARM group. No statistically significant reductions in daytime sleepiness (ESS) were observed for any of the groups.

CONCLUSION

CBT-I alone and in combination with armodafinil caused significant improvement in sleep continuity. The addition of armodafinil did not appear to improve daytime sleepiness or enhance adherence to CBT-I.

Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion

The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.

Joint Consensus Statement of the American Academy of Sleep Medicine and Sleep Research Society on the Recommended Amount of Sleep for a Healthy Adult: Methodology and Discussion

The American Academy of Sleep Medicine and Sleep Research Society recently released a Consensus Statement regarding the recommended amount of sleep to promote optimal health in adults. This paper describes the methodology, background literature, voting process, and voting results for the consensus statement. In addition, we address important assumptions and challenges encountered during the consensus process. Finally, we outline future directions that will advance our understanding of sleep need and place sleep duration in the broader context of sleep health.

Association of obesity and sleep problems among breast cancer survivors: results from a registry-based survey study

PURPOSE

Sleep-related complaints are common among breast cancer survivors. However, the risk factors underlying sleep disturbances in this population are not completely understood. Some studies have shown that maintaining normal weight can result in a reduced risk of cancer-related symptoms, including sleep problems; however, data from published studies are not consistent. This study examined the associations between body mass index (BMI) and sleep-related complaints in breast cancer survivors.

METHODS

Self-reported survey data from 861 breast cancer survivors at a single institution were analyzed. BMI was calculated based on self-reported weight and height at the time of the survey. Daytime sleepiness was assessed using the Epworth Sleepiness Scale. Average sleep duration was calculated based on the reported hours of sleep on a typical weekday and weekend. Associations between BMI and the sleep outcomes were estimated using multivariable logistic regression.

RESULTS

In adjusted models, BMI was not significantly associated with either excessive daytime sleepiness or "short" sleep pattern (≤ 6 h) in our sample of breast cancer survivors. Younger age, presence of strong acute pain, and lower level of education were independent risk factors for excessive daytime sleepiness. African American race, presence of strong acute pain, and lower level of education were independent risk factors for being a short sleeper.

CONCLUSIONS

Findings from this study indicate that BMI is not independently associated with sleep-related outcomes among breast cancer survivors. More research is needed to identify cancer survivors who are at increased risk for sleep disturbances as well as the mechanisms that underlie such disturbances.

Marital status and optimism score among breast cancer survivors

PURPOSE

There are an increasing number of breast cancer survivors, but their psychosocial and supportive care needs are not well-understood. Recent work has found marital status, social support, and optimism to be associated with quality of life, but little research has been conducted to understand how these factors relate to one another.

METHODS

Survey data from 722 breast cancer survivors were analyzed to estimate the association between marital status and optimism score, as measured using the Life Orientation Test-Revised. Linear regression was used to estimate the relationship of marital status and optimism, controlling for potential confounding variables and assessing effect modification.

RESULTS

The results showed that the association between marital status and optimism was modified by time since breast cancer diagnosis. Specifically, in those most recently diagnosed (within 5 years), married breast cancer survivors had a 1.50 higher mean optimism score than unmarried survivors (95 % confidence interval (CI) 0.37, 2.62; p = 0.009). The difference in optimism score by marital status was not present more than 5 years from breast cancer diagnosis.

CONCLUSIONS

Findings suggest that among breast cancer survivors within 5 years since diagnosis, those who are married have higher optimism scores than their unmarried counterparts; this association was not observed among longer-term breast cancer survivors. Future research should examine whether the difference in optimism score among this subgroup of breast cancer survivors is clinically relevant.