Comparison of subjectively and objectively assessed sleep problems in breast cancer patients starting neoadjuvant chemotherapy

Sleep quality in cancer patients: a common metric for several instruments measuring sleep quality

PURPOSE

Sleep problems are frequently observed in cancer patients. Multiple questionnaires for assessing sleep quality have been developed. The aim of this study was to present transfer rules that allow the conversion of the patients' scores from one questionnaire to another. In addition, we anchored this common metric to the general population.

METHODS

A sample of 1,733 cancer patients completed the following questionnaires: Pittsburgh Sleep Quality Index, Insomnia Sleep Index, Jenkins Sleep Scale, EORTC QLQ-C30, and the sleep scale of the EORTC QLQ-SURV100. The methods for establishing a common metric were based on Item Response Theory.

RESULTS

The main result of the study is a figure that allows the conversion from one of the above-mentioned sleep scales into another. Furthermore, the scores of the questionnaires can be transferred to theta scores that indicate the position within the group of cancer patients and also to T scores that indicate the position in relation to the general population. The correlations between the sleep scales ranged between 0.70 and 0.85.

CONCLUSIONS

The conversion rules presented in the study enable researchers and clinicians to directly compare single scores or mean scores across studies using different sleep scales, to assess the degree of sleep problems with regard to the general population, and to relate cutoff scores from one questionnaire to another.

Does a multimodal prehabilitation program improve sleep quality and duration in patients undergoing colorectal resection for cancer? Pilot randomized control trial

Sleep difficulties are a common symptom in cancer patients at different stages of treatment trajectory and may lead to numerous negative consequences for which management is required. This pilot Randomized Controlled Trial (RCT) aims to assess the potential effectiveness of home-based prehabilitation intervention (prehab) on sleep quality and parameters compared to standard care (SOC) in colorectal cancer patients during the preoperative period and up to 8 weeks after the surgery. One hundred two participants (48.3% female, mean age 65 years) scheduled for elective resection of colorectal cancer were randomized to the prehab (n = 50) or the SOC (n = 52) groups. Recruitment and retention rates were 54% and 72%, respectively. Measures were completed at the baseline and preoperative, 4- and 8-week after-surgery follow-ups. Our mixed models' analyses revealed no significant differences between groups observed over time for all subjective and objective sleep parameters. A small positive change was observed in the perceived sleep quality only at the preoperative time point for the prehabilitation group compared to the SOC group, with an effect size d = 0.11 and a confidence interval (CI) between - 2.1 and - 0.1, p = .048. Prehab group patients with high anxiety showed a significant improvement in the rate of change of sleep duration over time compared to the SOC group, with a difference of 110 min between baseline and 8 weeks after surgery (d = 0.51, 95% CI: 92.3 to 127.7, p = .02). Multimodal prehabilitation intervention is feasible in colorectal cancer patients and may improve sleep duration for patients with high anxiety symptoms. Future large-scale RCTs are needed to confirm our results.

Sleep dysfunction associated with worse chemotherapy-induced peripheral neurotoxicity functional outcomes

PURPOSE

Sleep problems are commonly reported by cancer survivors; however, knowledge of the impact of chemotherapy-induced peripheral neurotoxicity (CIPN) on sleep quality remains limited. In this study, we explored the impact of CIPN on sleep quality, as well as identified clinical characteristics associated with poor sleep quality.

METHODS

Participants were assessed cross-sectionally post-neurotoxic chemotherapy. CIPN severity was graded using a range of questionnaires that assessed CIPN severity and quality of life, as well as neurological grading scales. Sleep quality was assessed using a self-rated questionnaire (Pittsburgh Sleep Quality Index, PSQI). Participants with poor sleep quality were further grouped according to whether sleep impairment was due to CIPN or other factors.

RESULTS

Among 77 participants who reported CIPN, 75% (n = 58) reported poor sleep quality. Of those, 41% (n = 24) reported CIPN as contributing to sleep impairment, while 59% (n = 34) reported other causes. Participants with CIPN-induced sleep impairments had higher CIPN severity across all outcome measures, as well as greater neuropathic pain (all p < 0.05). Furthermore, participants with CIPN-induced sleep impairments reported worse impact of neuropathy on physical and social functioning, as well as emotional well-being (all p < 0.05).

CONCLUSIONS

Participants with CIPN-induced poor sleep quality reported worse scores across all CIPN severity measures. This emphasises the negative impacts of CIPN symptoms on quality of life of chemotherapy-treated patients and highlights the importance of sleep quality assessment in cancer survivors.

Sleep-wake state discrepancy among cancer survivors with insomnia symptoms

PURPOSE

To evaluate the discrepancy and correlation between sleep-wake measures (i.e., time in bed (TIB), total sleep time (TST), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency (SE%)) reported on sleep diary and measured by actigraphy among cancer survivors with insomnia symptoms; and examine the influences of sociodemographic and clinical variables on these measurement differences.

METHODS

A heterogenous sample of cancer survivors with insomnia symptoms (n = 120; M age = 63.7 ± 10.1; female = 58.3%) was included. Seven consecutive days of sleep diary and actigraphic data were obtained along with information on demographic, sleep, and mental health symptoms. Bland-Altman plot, Pearson correlation coefficient, concordance correlation coefficient, and mixed linear model approach were used to conduct the analysis.

RESULTS

Self-reported TIB, SOL, and WASO were longer than measured by actigraphy (TIB: 8.6 min. (95% CI, 3.7, 13.5; p < .001); SOL: 14.8 min. (95% CI, 9.4, 20.2; p < .0001); and WASO: 20.7 min. (95% CI, 9.4, 20.2; p < .0001), respectively); and self-reported TST and SE% were shorter than measured by actigraphy (TST: 6.8 min. (95% CI, -18.7, 5.13); and SE%: 0.7% (95%CI, -3.0, 2.0), respectively), but were not statistically significant. Sex, higher insomnia severity, and poor sleep quality were associated with discrepancy between several sleep-wake measures.

CONCLUSION

Subjective and objective sleep-wake measures may present discrepant finding among cancer survivors with symptoms of insomnia. Future research is needed to validate appropriate sleep-wake assessment, and better understand factors that influence the discrepancy that exists between measures among this population.

CLINICAL TRIAL REGISTRATION

Clinical trials identifier: NCT03810365. Date of registration: January 14, 2019.

Tackling Insomnia Symptoms through Vestibular Stimulation in Patients with Breast Cancer: A Perspective Paper

Insomnia symptoms are common among patients with breast cancer (BC; 20-70%) and are predictors of cancer progression and quality of life. Studies have highlighted sleep structure modifications, including increased awakenings and reduced sleep efficiency and total sleep time. Such modifications may result from circadian rhythm alterations consistently reported in this pathology and known as carcinogenic factors, including lower melatonin levels, a flattened diurnal cortisol pattern, and lower rest-activity rhythm amplitude and robustness. Cognitive behavioral therapy and physical activity are the most commonly used non-pharmacological interventions to counter insomnia difficulties in patients with BC. However, their effects on sleep structure remain unclear. Moreover, such approaches may be difficult to implement shortly after chemotherapy. Innovatively, vestibular stimulation would be particularly suited to tackling insomnia symptoms. Indeed, recent reports have shown that vestibular stimulation could resynchronize circadian rhythms and improve deep sleep in healthy volunteers. Moreover, vestibular dysfunction has been reported following chemotherapy. This perspective paper aims to support the evidence of using galvanic vestibular stimulation to resynchronize circadian rhythms and reduce insomnia symptoms in patients with BC, with beneficial effects on quality of life and, potentially, survival.

Stellate Ganglion Block Improves Postoperative Sleep Quality and Analgesia in Patients with Breast Cancer: A Randomized Controlled Trial

INTRODUCTION

Postoperative impaired sleep quality and pain are associated with adverse outcomes. Stellate ganglion block (SGB) has shown promising results in enhancing sleep quality and alleviating neuropathic pain. This study aimed to investigate the effects of ultrasound-guided SGB on postoperative sleep quality and pain in patients undergoing breast cancer surgery.

METHODS

This study is a parallel-group randomized controlled clinical trial with two groups: SGB and control. Fifty female patients undergoing breast cancer surgery were randomized in a 1:1 ratio to receive preoperative ultrasound-guided single-injection SGB (SGB group) or just an ultrasound scan (control group). All participants were blinded to the group assignment. The primary outcome was postoperative sleep quality, assessed by the St. Mary's Hospital Sleep Questionnaire and actigraphy 2 days postoperatively. The secondary outcome was postoperative pain, measured by the visual analog scale.

RESULTS

A total of 48 patients completed the study, with 23 patients in the control group and 25 in the SGB group. The postoperative St. Mary's Hospital Sleep Questionnaire scores were significantly higher in the SGB group than in the control group on 1 day postoperative (30.88 ± 2.44 versus 27.35 ± 4.12 points, P = 0.001). The SGB also increased the total sleep time and sleep efficiency (main actigraphy indicators) during the first two postoperative nights. Compared with the control group, preoperative SGB reduced postoperative pain and the incidence of breast cancer-related lymphedema (20% versus 52.2%, P = 0.02, odds ratio 0.229, 95% confidence interval 0.064-0.821). There were no adverse events related to SGB.

CONCLUSION

Preoperative ultrasound-guided SGB improves postoperative sleep quality and analgesia in patients undergoing breast cancer surgery. SGB may be a safe and practical treatment to enhance the postoperative quality of life in patients with breast cancer.

TRIAL REGISTRATION

The study was registered in the Chinese Clinical Trial Registry (ChiCTR2100046620, principal investigator: Kai Zeng, date of registration: 23 May 2021).

Poor Subjective Sleep Quality Among Patients with Cancer and Comorbid Depression: An Opportunity to Inform Screening and Intervention

OBJECTIVE

Sleep disturbances are under-identified and under-treated in oncology settings, especially for underserved populations and those with psychiatric comorbidities. This study examined the prevalence and correlates of poor subjective sleep quality as well as clinical sleep recommendations among a socioeconomically and ethnically diverse population of patients with cancer referred for depression management.

METHODS

Participants were 140 adults with cancer who screened positive for depression through routine, practice-based assessment with the Patient Health Questionnaire (PHQ-9 ≥ 8) and were referred to a study of collaborative care for depression. Demographics, clinical characteristics, subjective sleep quality, and sleep recommendations received were self-reported by patients prior to intervention. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI), general health status was measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10, and depressive symptoms were measured using the PHQ-9.

RESULTS

Of 138 patients with complete data, 123 (89.1%) reported poor sleep quality, and 87 (63%) met the threshold for possible insomnia. The strongest correlates of poor subjective sleep were female gender (β = 0.19, p = .02), greater depressive symptom severity (β = 0.28, p = .001), and worse physical health (β = -0.19, p = .04). Of 118 patients reporting problems with sleep since their cancer diagnosis, 95 discussed the issue with a medical provider; medications were recommended most often (37; 38.9%); only 9 (9.5%) received recommendations for cognitive-behavioral therapy for insomnia (CBT-I) or other CBT.

CONCLUSIONS

Patients with cancer seeking treatment for depression report very high rates of poor subjective sleep quality and insomnia, underscoring the importance of providing and referring to guideline-concordant sleep interventions in oncology supportive care contexts.

Association of Sleep and Physical Activity Among Older Adults and the Moderation of Chronotype

This study aimed to examine the associations of both subjectively and objectively measured sleep with physical activity among older adults and to explore the possible moderating role of chronotype in these associations. We included baseline data of 116 community-dwelling older adults without dementia from three prior studies. Pittsburgh Sleep Quality Index and Actigraphy were used as subjective and objective sleep measures, respectively. Physical activity was assessed by the Physical Activity Scale for the Elderly. The Morningness-Eveningness Questionnaire was used to measure chronotype, which was further dichotomized into morning type and non-morning type. Multiple linear regressions were performed to examine the associations, controlling for demographic and health characteristics. We found that better subjective sleep quality, shorter actigraphy sleep duration, and higher actigraphy sleep efficiency were uniquely associated with greater physical activity. Being a morning type might alleviate the adverse association between poor subjective sleep quality and physical activity among older adults.

Is unemployment associated with inefficient sleep habits? A cohort study using objective sleep measurements

Unemployed people could be at risk of developing inefficient sleep habits by spending excessive time in bed, as they lack a structuring activity. This could impact their mental health and reintegration into labour. This study aims to analyse possible associations between employment status and sleep parameters using actigraphy. Subjects (148 employed and 50 unemployed) were drawn from a German population-based cohort. Sleep parameters were measured with the SenseWear Bodymedia Pro 3 armband. Comparison of means concerning sleep duration, sleep efficiency, time of sleep and sleep fragmentation was performed separately for week days and weekends. Multiple linear regression analysis was performed to analyse group differences controlling for covariates. Finally, we defined cut-off scores for each sleep variable, and analysed the distribution of subjects above and below these values. Unemployed people did not sleep significantly longer than employed people. However, on week days, they displayed night sleep efficiency reduced by on average > 5% points, they lay down for 28 min longer, had later mid sleep time (38 min) and sleep offset (55 min), as well as more frequent awakenings after sleep onset accounting for being awake 28 min longer (all p ≤ 0.005). Sleep in unemployed subjects compared with employed subjects aged 41-64 years was less efficient, more fragmented and shifted to a later point of the night. Results support prior findings that unemployment has a negative influence on sleep quality. Unemployed individuals could benefit from intervention programmes aiming at the adoption of healthier sleep habits.

Digital phenotyping of sleep patterns among heterogenous samples of Latinx adults using unsupervised learning

OBJECTIVE

This study aimed to identify sleep disturbance subtypes ("phenotypes") among Latinx adults based on objective sleep data using a flexible unsupervised machine learning technique.

METHODS

This study was an analysis of sleep data from three cross-sectional studies of the Precision in Symptom Self-Management Center at Columbia University. All studies focused on sleep health in Latinx adults at increased risk for sleep disturbance. Data on total sleep time (TST), time in bed (TIB), wake after sleep onset (WASO), sleep efficiency (SE), number of awakenings (NOA) and the mean length of nightly awakenings were collected using wrist-mounted accelerometers. Cluster analysis of the sleep data was conducted using an unsupervised machine learning approach that relies on mixtures of multivariate generalized linear mixed models.

RESULTS

The analytic sample included 494 days of data from 118 adults (Ages 19-77). A 3-cluster model provided the best fit based on deviance indices (ie, DΔ∼ -75 and -17 from 1- and 2- to 3-cluster models, respectively) and likelihood ratio (P_diff ∼ 0.93). Phenotype 1 (n = 64) was associated with greater likelihood of overall adequate SE and less variability in SE and WASO. Phenotype 2 (n = 11) was characterized by higher NOAs, and greater WASO and TIB than the other phenotypes. Phenotype 3 (n = 43) was characterized by greater variability in SE, bed times and awakening times.

CONCLUSION

Robust digital data-driven modeling approaches can be useful for detecting sleep phenotypes from heterogenous patient populations, and have implications for designing precision sleep health strategies for management and early detection of sleep problems.

Factors associated with sleep disturbances in women undergoing treatment for early-stage breast cancer

PURPOSE

The purpose of this study was to examine factors associated with sleep disturbance in women receiving adjuvant therapy for breast cancer.

METHODS

This study employed a cross-sectional design using data collected at 3 months post-surgery from an ongoing longitudinal parent study. Participant data were divided into adjuvant treatment groups (chemotherapy, radiation, and aromatase inhibitors) and no adjuvant treatment groups. Symptoms were measured using patient self-report measures. Analysis of variance was used to assess between adjuvant treatment group differences in sleep disturbance. Regression analysis was performed to assess the relationship between sleep disturbance and other symptoms within adjuvant treatment groups.

RESULTS

The sample included 156 women diagnosed with early-stage breast cancer. There were significant differences in levels of reported sleep disturbance between treatment groups (p = 0.049), with significantly higher levels of sleep disturbances in those receiving radiation compared to those receiving no adjuvant treatment (p = 0.038) and in those receiving chemotherapy and those receiving no adjuvant treatment (p = 0.027). Increased sleep disturbance was found to be a significant predictor for increased pain severity, nausea severity, anxiety, depressive symptoms, fatigue, decreased physical function, and decreased ability to participate in social roles and activities. Co-occurring symptoms with sleep disturbance differed between adjuvant treatment groups. Sleep disturbance was also associated with younger age (p = 0.008).

CONCLUSIONS

Patients undergoing chemotherapy or radiation for breast cancer report higher levels of sleep disturbance than those not receiving adjuvant therapy. Sleep disturbance is associated with other symptoms experienced by patients with cancer and thus requires continual assessment and future research into effective interventions.

Sleep Quality among Breast and Prostate Cancer Patients: A Comparison between Subjective and Objective Measurements

Breast and prostate cancer patients may experience physical and psychological distress, and a possible decrease in sleep quality. Subjective and objective methods measure different aspects of sleep quality. Our study attempted to determine differences between objective and subjective measurements of sleep quality using bivariate and Pearson's correlation data analysis. Forty breast (n = 20) and prostate (n = 20) cancer patients were recruited in this observational study. Participants were given an actigraphy device (ACT) and asked to continuously wear it for seven consecutive days, for objective data collection. Following this period, they filled out the Pittsburgh Sleep Quality Index Questionnaire (PSQI) to collect subjective data on sleep quality. The correlation results showed that, for breast cancer patients, PSQI sleep duration was moderately correlated with ACT total sleeping time (TST) (r = -0.534, p < 0.05), and PSQI daytime dysfunction was related to ACT efficiency (r = 0.521, p < 0.05). For prostate cancer patients, PSQI sleep disturbances were related to ACT TST (r = 0.626, p < 0.05). Both objective and subjective measurements are important in validating and determining details of sleep quality, with combined results being more insightful, and can also help in personalized care to further improve quality of life among cancer patients.

Assessment of sleep problems with the Insomnia Severity Index (ISI) and the sleep item of the Patient Health Questionnaire (PHQ-9) in cancer patients

Objective

The objectives of this study were to examine sleep problems in cancer patients, to test the psychometric properties of the Insomnia Sleep Index (ISI) in comparison with the sleep item of the Patient Health Questionnaire-9 (PHQ-9), and to analyze disrupting factors which might cause the sleep problems.

Methods

A sample of 1026 mixed-site cancer patients in treatment at a German oncological rehabilitation clinic was examined.

Results

The reliability of the ISI was very good (Cronbach’s alpha = 0.92), and the results of the confirmatory factor analysis were acceptable. Females reported worse sleep quality (ISI mean: 13.7 ± 6.6) than males (10.7 ± 6.4). Sleep problems as measured with the PHQ-9 sleep item were markedly higher than those in the general population (effect size d = 1.15).

Patients reported that, of the factors that disrupted their sleep, psychological factors (brooding, worries) were more relevant than symptom factors (pain, nocturnal urination, or restless legs).

Conclusions

The ISI is effective in detecting sleep problems in cancer patients. Normative studies with the ISI would be helpful for assessing ISI mean scores. Sex differences should be taken into account when groups of patients are compared. The sleep item of the PHQ-9 can be used in epidemiological studies.

Cancer outcomes research-a European challenge: measures of the cancer burden

In a mission that aims to improve cancer control throughout Europe, the European Academy of Cancer Sciences has defined two key indicators of progress: within one to two decades, overall cancer-specific 10-year survival should reach 75%, and in each country, overall cancer mortality rates should be convincingly declining. To lay the ground for assessment of progress and to promote cancer outcomes research in general, we have reviewed the most common population-based measures of the cancer burden. We emphasize the complexities and complementary approaches to measure cancer survival and the novel opportunities for improved assessment of quality of life. We propose that: incidence and mortality rates are standardized to the European population; net survival is used as the measure of prognosis but with proper adjustments for confounding when temporal trends in overall cancer survival are assessed; and cancer-specific quality of life is measured by a combination of existing questionnaires and utilizes emerging communication technologies. We conclude that all measures are important and that a meaningful interpretation also requires a deep understanding of the larger clinical and public health context.

Effects of Morning Blue-Green 500 nm Light Therapy on Cognition and Biomarkers in Middle-Aged and Older Adults with Subjective Cognitive Decline and Mild Cognitive Impairment: Study Protocol for a Randomized Controlled Trial

BACKGROUND

Given that there is no specific drug to treat Alzheimer's disease, non-pharmacologic interventions in people with subjective cognitive decline (SCD) and amnestic mild cognitive impairment (aMCI) are one of the most important treatment strategies.

OBJECTIVE

To clarify the efficacy of blue-green (500 nm) light therapy on sleep, mood, and physiological parameters in patients with SCD and aMCI is an interesting avenue to explore.

METHODS

This is a monocentric, randomized, and controlled trial that will last for 4 weeks. We will recruit 150 individuals aged 45 years or older from memory clinics and divide them into 5 groups: SCD treatment (n = 30), SCD control (n = 30), aMCI treatment (n = 30), aMCI control (n = 30), and a group of healthy adult subjects (n = 30) as a normal control (NC).

RESULTS

The primary outcome is the change in subjective and objective cognitive performance between baseline and postintervention visits (4 weeks after baseline). Secondary outcomes include changes in performance assessing from baseline, postintervention to follow-up (3 months after the intervention), as well as sleep, mood, and physiological parameters (including blood, urine, electrophysiology, and neuroimaging biomarkers).

CONCLUSION

This study aims to provide evidence of the impact of light therapy on subjective and objective cognitive performance in middle-aged and older adults with SCD or aMCI. In addition, we will identify possible neurophysiological mechanisms of action underlying light therapy. Overall, this trial will contribute to the establishment of light therapy in the prevention of Alzheimer's disease.