Use of tranquilizers and sleeping pills among cancer patients is associated with a poorer quality of life

Efficacy of traditional Chinese medicine external therapy on sleep quality in patients with cancer: A systematic review and network meta-analysis

Objective

This network meta-analysis aims to assess and compare the effectiveness of various external therapies from traditional Chinese medicine (TCM) in enhancing sleep quality among patients with cancer.

Methods

We systematically searched nine electronic databases, encompassing five English and four Chinese databases, for randomized controlled trials (RCTs) from their inception up to August 10, 2023. The random effects model was utilized for effect size analysis, and the standardized mean difference (SMD) along with its corresponding 95% confidence interval (CI) were computed. Network meta-analysis and comparative effects ranking were executed utilizing STATA 14.0.

Results

We included thirty-four RCTs involving seven distinct external TCM therapies. Among these, Chinese medicine pillow (SMD = -3.27; 95% CI: -6.03 to -0.51), auricular acupressure (SMD = -2.33; 95% CI: -3.36 to -1.29), moxibustion (SMD = -2.28; 95% CI: -3.63 to -0.94), acupressure (SMD = -1.67; 95% CI: -2.64 to -0.70), and acupuncture (SMD = -1.43; 95% CI: -2.65 to -0.21) demonstrated significant effects in improving sleep quality when compared to usual care or waitlist. The cumulative ranking curve values revealed that the Chinese medicine pillow exhibited the highest potential for effectively enhancing sleep quality in patients with cancer, followed by auricular acupressure, moxibustion, acupressure, acupuncture, Tuina, and electroacupuncture.

Conclusions

Our study highlights the Chinese medicine pillow as an optimal external TCM therapy for ameliorating sleep quality in cancer patients, but more RCTs are needed to validate this conclusion. These findings serve as valuable support for future clinical trials and research endeavors.

Systematic review registration

CRD42022381370.

Auricular Acupressure for Improving Sleep Quality in Patients With Lung Cancer: A Systematic Review and Meta-analysis

This meta-analysis was conducted to systematically evaluate the efficacy and safety of auricular acupressure on sleep quality in patients with lung cancer. Nine articles with a total of 802 patients were retrieved after searching on 11 electronic databases. Results of the meta-analysis showed that auricular acupressure improved sleep score (standard mean difference: -0.80, 95% confidence intervals: -1.30 to -0.30, P = .002) and reduced sleep disturbance rate (risk ratio: 0.65, 95% confidence intervals: 0.51-0.84, P = .001) and sleep medicine usage (risk ratio: 0.26, 95% confidence intervals: 0.11-0.65, P = .004) significantly. Our review suggests that auricular acupressure is effective and relatively safe in improving sleep quality among patients with lung cancer.

Assessing the Sleep-wake Pattern in Cancer Patients for Predicting a Short Sleep Onset Latency

Objective

We investigated the sleep parameters and clinical factors related to short sleep onset latency (SL) in cancer patients.

Methods

We retrospectively reviewed the medical records of 235 cancer patients. Patient Health Questionnaire-9, State and Trait Anxiety Inventory (State subcategory), Insomnia Severity Index (ISI), Cancer-related Dysfunctional Beliefs about Sleep, and Fear of Progression scale scores and sleep related parameters including sleeping pill ingestion time, bedtime, sleep onset time, and wake-up time were collected. We also calculated the duration from sleeping pill ingestion to bedtime, sleep onset time, and wake-up time; duration from wake-up time to bedtime and sleep onset time; and time spent in bed over a 24 hours period.

Results

Among patients not taking sleeping pills (n = 145), early wake-up time (adjusted odds ratio [OR] 0.39, 95% confidence interval [CI] 0.19−0.78), early sleep onset time (OR 0.50, 95% CI 0.27−0.93), and low ISI score (OR 0.82, 95% CI 0.71−0.93) were identified as expecting variables for SL ≤ 30 minutes. Longer duration from wake-up time to bedtime (OR 2.49, 95% CI 1.48−4.18) predicted SL ≤ 30 minutes. Among those taking sleeping pills (n = 90), early sleep onset time (OR 0.54, 95% CI 0.39−0.76) and short duration from pill ingestion to sleep onset time (OR 0.05, 95% CI 0.02−0.16) predicted SL ≤ 30 minutes.

Conclusion

Cancer patients who fell asleep quickly spent less time in bed during the day. Thus, before cancer patients with insomnia are prescribed sleeping pills, their sleep parameters should be examined to improve their SL.

The influence of Chinese herbal medicines on cancer-related pressure ulcer wound, fatigue, constipation, and anorexia: A meta-analysis

We performed a meta-analysis to evaluate the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. A systematic literature search up to March 2022 was done and 25 studies included 1777 subjects with cancer-related symptoms at the start of the study; 953 of them were provided with Chinese herbal medicines and 824 were control. They were reporting relationships about the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia. We calculated the odds ratio (OR) with 95% confidence intervals (CIs) to assess the influence of Chinese herbal medicines on cancer-related pressure ulcer wounds, fatigue, constipation, and anorexia using the dichotomous method with a random or fixed-effect model. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound (OR, 5.94; 95% CI, 3.94-8.95, P < .001), fatigue (OR, 2.81; 95% CI, 1.78-4.41, P < .001), and effectiveness on treating constipation (OR, 2.59; 95% CI, 1.57-4.25, P < .001) compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on treating anorexia (OR, 1.69; 95% CI, 0.61-4.66, P = .31) compared to control in subjects with cancer-related symptoms. Chinese herbal medicines had significantly higher effectiveness in treating pressure ulcer wound, treating pressure ulcer wound, fatigue, and constipation compared to control in subjects with cancer-related symptoms. However, Chinese herbal medicines had no significant effect on the effectiveness of treating anorexia compared to control in subjects with cancer-related symptoms. Further studies are required to validate these findings.

Insomnia as an Unmet Need in Chronic Hematologic Cancer Patients: A study design of a randomized controlled trial evaluating a consumer-based meditation app for treatment of sleep disturbance (Preprint)

Background

To address the need for long-term, accessible, nonpharmacologic interventions targeting sleep in patients with chronic hematological cancer, we propose the first randomized controlled trial to determine the effects of a consumer-based mobile meditation app, Calm, on sleep disturbance in this population.

Objective

This study aims to test the efficacy of daily meditation delivered via Calm compared with a health education podcast control group in improving the primary outcome of self-reported sleep disturbance, as well as secondary sleep outcomes, including sleep impairment and sleep efficiency; test the efficacy of daily meditation delivered via Calm compared with a health education podcast control group on inflammatory markers, fatigue, and emotional distress; and explore free-living use during a 12-week follow-up period and the sustained effects of Calm in patients with chronic hematological cancer.

Methods

In a double-blinded randomized controlled trial, we will recruit 276 patients with chronic hematological cancer to an 8-week app-based wellness intervention—the active, daily, app-based meditation intervention or the health education podcast app control group, followed by a 12-week follow-up period. Participants will be asked to use their assigned app for at least 10 minutes per day during the 8-week intervention period; complete web-based surveys assessing self-reported sleep disturbance, fatigue, and emotional distress at baseline, 8 weeks, and 20 weeks; complete sleep diaries and wear an actigraphy device during the 8-week intervention period and at 20 weeks; and complete blood draws to assess inflammatory markers (tumor necrosis factor-α, interleukin-6, interleukin-8, and C-reactive protein) at baseline, 8 weeks, and 20 weeks.

Results

This project was funded by the National Institutes of Health National Cancer Institute (R01CA262041). The projects began in April 2022, and study recruitment is scheduled to begin in October 2022, with a total project duration of 5 years. We anticipate that we will be able to achieve our enrollment goal of 276 patients with chronic hematological cancers within the allotted project time frame.

Conclusions

This research will contribute to broader public health efforts by providing researchers and clinicians with an evidence-based commercial product to improve sleep in the long term in an underserved and understudied cancer population with a high incidence of sleep disturbance.

Trial Registration

ClinicalTrials.gov NCT05294991; https://clinicaltrials.gov/ct2/show/NCT05294991

International Registered Report Identifier (IRRID)

PRR1-10.2196/39007

Traditional Herbal Medicine for Insomnia in Patients With Cancer: A Systematic Review and Meta-Analysis

Background: Insomnia is one of the most prevalent cancer-related symptoms and has a severe impact on the quality of life. This study aimed to evaluate the efficacy and safety of traditional herbal medicine (THM) for improving sleep quality in patients with cancer. Methods: Randomized controlled trials (RCTs) evaluating orally administered THM in a cancer population with insomnia were searched using nine electronic databases up to November 30, 2020. The outcome measurements were sleep quality measured by validated questionnaire such as the Pittsburgh Sleep Quality Index (PSQI), total effective rate, and adverse effects. The included studies were appraised using the Cochrane risk of bias tool and meta-analyzed. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. Results: Fourteen RCTs were included in the systematic review, and 10 RCTs were analyzed quantitatively. Compared to hypnotics, THM showed a significant improvement in sleep quality by reducing the PSQI score [mean difference (MD) -2.25, 95% confidence interval (CI) -3.46 to -1.05, I 2 = 84%] and increasing the total effective rate [risk ratio (RR) 1.26, 95% CI 1.07 to 1.48, I 2 = 70%] with low quality of evidence. Compared to placebo, THM also reduced the PSQI score significantly (MD -2.56, 95% CI -3.81 to -1.31, I 2 = 91%) with moderate quality of evidence. The most frequently used herbs were Ziziphus jujuba Mill. No serious adverse events were observed. Conclusion: This review suggests that THM may be an effective therapeutic option for insomnia in patients with cancer. However, considering the limited methodological qualities and inconsistent results of the included trials, further rigorous RCTs are required. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero], PROSPERO 2021 [CRD42021265070].

Psychotropic polypharmacy and its association with health-related quality of life among cancer survivors in the USA: a population-level analysis

PURPOSE

Cancer survivors that use multiple psychotropic medications are at an increased risk of psychotropic polypharmacy. We examined the association between psychotropic polypharmacy and health-related quality of life (HRQoL) among cancer survivors living in the USA.

METHODS

We used the Medical Expenditure Panel Survey (MEPS) data for 2010, 2012, and 2014 to identify adult cancer survivors. Psychotropic polypharmacy was defined as use of at least two classes of psychotropic prescription medications. The physical component summary (PCS) and the mental component summary (MCS) were obtained from the 12-item Short Form Health Survey version 2 to measure HRQoL. Adjusted ordinary least square regressions were performed to evaluate the association between psychotropic polypharmacy and HRQoL.

RESULTS

Among 31 million US cancer survivors (weighted from a sample of 2609), 16.3% reported psychotropic polypharmacy. Lung cancer survivors had the highest prevalence of psychotropic polypharmacy (22.5%), followed by survivors of breast cancer (17.8%), colorectal, and other gastrointestinal cancers (16.0%). The unadjusted PCS and MCS scores for those with psychotropic polypharmacy were significantly lower than those without psychotropic polypharmacy, overall, and for each cancer type. In multivariable regressions, cancer survivors with psychotropic polypharmacy had significantly lower PCS scores (β =  - 3.63, p < 0.0001) and MCS scores (β =  - 2.28, p = 0.0138) compared to those without psychotropic polypharmacy.

CONCLUSION

Cancer survivors requiring multiple psychotropic medications have poorer quality of life.

Beyond Prescriptions Monitoring Programs: The Importance of Having the Conversation about Benzodiazepine Use

: Internationally there is an escalation of prescription-related overdose deaths, particularly related to benzodiazepine use. As a result, many countries have implemented prescription monitoring programs (PMPs) to increase the regulation of benzodiazepine medications. PMPs centralize prescription data for prescribers and pharmacists and generate alerts to high-doses, risky combinations, or multiple prescribers with the aim to reduce inappropriate prescribing and subsequently the potential of patient harm. However, it has become clear that prescribers have been provided with minimal guidance and insufficient training to effectively integrate PMP information into their decision making around prescribing these medications. Accordingly, this paper discusses how PMPs have given rise to a range of unintended consequences in those who have been prescribed benzodiazepines (BDZs). Given that a gradual taper is generally required to mitigate withdrawal from BDZs, there are concerns that alerts from PMPs have resulted in BDZs being ceased abruptly, resulting in a range of unintended harms to patients. It is argued that best practice guidelines based upon a patient-centered framework of decision-making, need to be developed and implemented, in order to curtail the unintended consequences of PMPs. This paper outlines some key considerations when starting the conversation with patients about their BDZ use.

Elucidating the associations between sleep disturbance and depression, fatigue, and pain in older adults with cancer

OBJECTIVES

Sleep disturbance is prevalent and often coexists with depression, fatigue, and pain in the cancer population. The aim of this study was to describe the prevalence of sleep disturbance with co-existing depression, fatigue, and pain in older patients with cancer. We also examined the associations of several socio-demographic and clinical variables with sleep disturbance.

METHODS

This cross-sectional study consisted of 389 older patients with solid and hematologic malignancies who were referred to the Specialized Oncology Care & Research in the Elderly (SOCARE) clinics at the Universities of Rochester and Chicago between May 2011 and October 2015 and completed a sleep and geriatric assessment (that inquires about fatigue, pain, and depression). Multivariate logistic regression was used to identify variables associated with sleep disturbance.

RESULTS

The prevalence of sleep disturbance was 40%. Of those with sleep disturbance (n = 154), 84% also had at least one of the other three symptoms (25% had one symptom, 38% had two symptoms, and 21% had three symptoms). Sleep disturbance was more likely to be reported in those with comorbidities (45% vs. 28%, P = 0.002), depression (49% vs. 36%, P = 0.015), fatigue (49% vs. 23%, P < 0.001), and pain (45% vs. 31%, P = 0.010). On multivariable analysis, only fatigue (adjusted odds ratio (AOR) 1.90, 95% CI 1.10-3.30, P = 0.020) was independently associated with sleep disturbance.

CONCLUSIONS

Sleep disturbance is prevalent and often co-occurs with depression, fatigue, or pain in older patients with cancer. Fatigue was significantly associated with sleep disturbance and future studies should explore interventions that target sleep disturbance and fatigue.

Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis

Use of Chinese herbal medicines (CHM) in symptom management for cancer palliative care is very common in Chinese populations but clinical evidence on their effectiveness is yet to be synthesized. To conduct a systematic review with meta-analysis to summarize results from CHM randomized controlled trials (RCTs) focusing on symptoms that are undertreated in conventional cancer palliative care.Five international and 3 Chinese databases were searched. RCTs evaluating CHM, either in combination with conventional treatments or used alone, in managing cancer-related symptoms were considered eligible. Effectiveness was quantified by using weighted mean difference (WMD) using random effect model meta-analysis. Fourteen RCTs were included. Compared with conventional intervention alone, meta-analysis showed that combined CHM and conventional treatment significantly reduced pain (3 studies, pooled WMD: -0.90, 95% CI: -1.69 to -0.11). Six trials comparing CHM with conventional medications demonstrated similar effect in reducing constipation. One RCT showed significant positive effect of CHM plus chemotherapy for managing fatigue, but not in the remaining 3 RCTs. The additional use of CHM to chemotherapy does not improve anorexia when compared to chemotherapy alone, but the result was concluded from 2 small trials only. Adverse events were infrequent and mild. CHM may be considered as an add-on to conventional care in the management of pain in cancer patients. CHM could also be considered as an alternative to conventional care for reducing constipation. Evidence on the use of CHM for treating anorexia and fatigue in cancer patients is uncertain, warranting further research.

Sleep and fatigue in pediatric oncology: A review of the literature

Cancer in children has detrimental effects on sleep patterns and sleep quality, which in turn impacts on the perception of, and the ability to cope with, the emotional and physical challenges associated with both the disease and its treatment. This places an added burden on their quality of life that can last many years beyond diagnosis and treatment. In addition to the effect of the cancer itself, surgery, chemotherapy and radiotherapy can all contribute both short and long term to sleep disruption. Sleep disorders have also been associated with pain, fatigue, medication and hospitalisation in children suffering from cancer. This review will explore the relationship between childhood cancer and associated sleep disorders, in the acute stage of diagnosis, during treatment and in the years following. We will discuss the possible causes and the current treatment modalities used to treat sleep disorders in children with cancer, and in childhood cancer survivors. It has been estimated that the recent advances in treatment have improved the overall five year survival rate for all childhood cancers to over 80%, with some cancers achieving a near 100% cure rate such as early stage Wilms' tumour. Thus, recognition and appropriate treatment of associated sleep disorders is essential to optimise long term quality of life.

A phase 3 trial of armodafinil for the treatment of cancer-related fatigue for patients with multiple myeloma

PURPOSE

Fatigue is a common problem among multiple myeloma (MM) patients. Armodafinil is a drug known to promote wakefulness, which is related to modafinil, a compound that improves fatigue in some cancer patients treated with chemotherapeutic agents. We investigated whether armodafinil could reduce cancer-related fatigue in MM patients.

METHODS

This double-blind, placebo-controlled phase 3 trial evaluated the efficacy of armodafinil in MM patients with evidence of moderate fatigue. Patients were randomized to one of two arms: treatment-only, with armodafinil given at 150 mg/daily for 56 days, or placebo-first, with placebo given on days 1-28, followed by armodafinil administered at 150 mg daily on days 29-56. Fatigue was measured on days 1 (pre-dose: baseline), 15, 28, 43, and 56 using seven separate assessments, including four patient-reported outcomes of fatigue and related quality of life measures, as well as three objective measures of cognitive function.

RESULTS

Overall toxicities were similar between treatment groups. No significant differences were observed between the placebo-first and the treatment-only arms after 28 days. Treatment with armodafinil for 28 additional days did not produce responses. Both placebo-first and treatment-only patients showed similar significant improvements in three patient-reported measures and one objective task at day 28 compared to baseline. Placebo-first patients improved on eight additional measures (one patient-reported measure, six subscales, and one objective task), suggesting a strong placebo effect in this patient population.

CONCLUSIONS

Evaluation and treatment of cancer-related fatigue continues to be challenging; a clear definition of this symptom and better assessment tools are needed.

Update on the role of melatonin in the prevention of cancer tumorigenesis and in the management of cancer correlates, such as sleep-wake and mood disturbances: review and remarks

The aim of this article was to perform a systematic review on the role of melatonin in the prevention of cancer tumorigenesis--in vivo and in vitro--as well as in the management of cancer correlates, such as sleep-wake and mood disturbances. The International Agency for Research on Cancer recently classified "shift-work that involves circadian disruption" as "probably carcinogenic to humans" (Group 2A) based on "limited evidence in humans for the carcinogenicity of shift-work that involves night-work", and "sufficient evidence in experimental animals for the carcinogenicity of light during the daily dark period (biological night)". The clinical implications and the potential uses of melatonin in terms of biologic clock influence (e.g. sleep and mood), immune function, cancer initiation and growth, as well as the correlation between melatonin levels and cancer risk, are hereinafter recorded and summarized. Additionally, this paper includes a description of the newly discovered effects that melatonin has on the management of sleep-wake and mood disturbances as well as with regard to cancer patients' life quality. In cancer patients depression and insomnia are frequent and serious comorbid conditions which definitely require a special attention. The data presented in this review encourage the performance of new clinical trials to investigate the possible use of melatonin in cancer patients suffering from sleep-wake and mood disturbances, also considering that melatonin registered a low toxicity in cancer patients.

Troublesome symptoms in cancer survivors: fatigue, insomnia, neuropathy, and pain

Patients with cancer suffer from a variety of symptoms associated with both cancer and its treatment. These symptoms may lead to a decreased quality of life for patients and can affect compliance with cancer therapies. The importance of adequately treating cancer-related symptoms is gaining more attention but, overall, many symptoms remain underdiagnosed and undertreated. Fatigue, insomnia, neuropathy, and pain are among the most common troublesome symptoms experienced by cancer survivors. This article will focus on the management of these symptoms, including an assessment of the current research and proposed best- management practices.

Self-reported cognitive impairment after breast cancer treatment in young women from the ELIPPSE40 cohort: the long-term impact of chemotherapy

Cognitive impairment (CI) is common after cancer treatments, but little is known about the long-term evolution of CI, especially in premenopausal women. Since September 2005, all consecutive women included in the French National Health Insurance Fund registry with a diagnosis of primary breast cancer, aged 18-40 years and living in South Eastern France, were asked to participate in a cohort study, including telephone interviews, medical data, and prescription refills of psychotropic drugs and adjuvant endocrine therapy. At each interview, CI is defined as self-report of frequent memory loss and attention deficits. As of February 2010, 222 women with available medical data had taken part in the 10-, 16-, and 28-month telephone interviews, with CI being reported by 37.4%, 36.5%, and 42.3% of participants, respectively. Tranquilizers' dispensation was associated with CI self-report at all three interviews; chemotherapy was reported only at the 28-month interview. At 28 months, besides chemotherapy and tranquilizer's dispensation, having a low educational level and not being a native French woman were also independently associated with CI. Reports of CI were common in young women and primarily related to psycho-social vulnerabilities and cancer treatment. As they affect quality of life, long-term CI complaints deserve greater consideration.

The Symptom Cluster of Sleep, Fatigue and Depressive Symptoms in Breast Cancer Patients: Severity of the Problem and Treatment Options

Breast cancer is the most commonly diagnosed cancer in women. Insomnia is a significant problem in breast cancer patients, affecting between 20% to 70% of newly diagnosed or recently treated cancer patients. Pain, fatigue, anxiety, and depression are also common conditions in breast cancer and often co-occur with insomnia in symptom clusters, exacerbating one another, and decreasing quality of life (QOL). There have been no clinical trials of drugs for sleep in cancer. Cognitive behavioral psychotherapies on the other hand, have shown some of the most positive results in alleviating the distressing symptoms that often accompany the breast cancer experience, but even these studies have not targeted the symptom cluster. Pharmacological as well as non-pharmacological treatments need to be explored. It might be that a combined pharmacological and behavioral treatment is most efficacious. In short, substantially more research is needed to fully understand and treat the symptom cluster of insomnia, fatigue, pain, depression and anxiety in breast cancer.

Benzodiazepines revisited--will we ever learn?

AIMS

To re-examine various aspects of the benzodiazepines (BZDs), widely prescribed for 50 years, mainly to treat anxiety and insomnia. It is a descriptive review based on the Okey Lecture delivered at the Institute of Psychiatry, King's College London, in November 2010.

METHODS

A search of the literature was carried out in the Medline, Embase and Cochrane Collaboration databases, using the codeword 'benzodiazepine(s)', alone and in conjunction with various terms such as 'dependence', 'abuse', etc. Further hand-searches were made based on the reference lists of key papers. As 60,000 references were found, this review is not exhaustive. It concentrates on the adverse effects, dependence and abuse.

RESULTS

Almost from their introduction the BZDs have been controversial, with polarized opinions, advocates pointing out their efficacy, tolerability and patient acceptability, opponents deprecating their adverse effects, dependence and abuse liability. More recently, the advent of alternative and usually safer medications has opened up the debate. The review noted a series of adverse effects that continued to cause concern, such as cognitive and psychomotor impairment. In addition, dependence and abuse remain as serious problems. Despite warnings and guidelines, usage of these drugs remains at a high level. The limitations in their use both as choice of therapy and with respect to conservative dosage and duration of use are highlighted. The distinction between low-dose 'iatrogenic' dependence and high-dose abuse/misuse is emphasized.

CONCLUSIONS

The practical problems with the benzodiazepines have persisted for 50 years, but have been ignored by many practitioners and almost all official bodies. The risk-benefit ratio of the benzodiazepines remains positive in most patients in the short term (2-4 weeks) but is unestablished beyond that time, due mainly to the difficulty in preventing short-term use from extending indefinitely with the risk of dependence. Other research issues include the possibility of long-term brain changes and evaluating the role of the benzodiazepine antagonist, flumazenil, in aiding withdrawal.

Does effective management of sleep disorders reduce cancer-related fatigue?

Cancer and cancer therapy are often associated with symptoms such as fatigue and sleep disturbances, before, during and after therapy. These symptoms of fatigue and poor sleep often occur in parallel having a significant impact on the physical functioning of patients with cancer. A strong correlation between cancer-related fatigue (CRF) and sleep has been observed in several studies, suggesting that they may be reciprocally related. The co-clustering of these symptoms suggests that they may have similar underlying aetiology and that treatments targeting either symptom may positively affect the other. Studies examining these clusters have shown that these symptoms often co-vary together. The potential mechanisms that link the relationship between insomnia and CRF are intriguing but require further investigation. Despite the high prevalence of insomnia and the often bidirectional relationship between poor sleep and fatigue, there are limited data to support the use of sleep management interventions as a means to reduce fatigue in patients with cancer. Assessment of the available evidence across trials is complicated by different study designs, patient selection criteria, stage of cancer treatment and by the nature of the interventions studied. Improvements from baseline in both sleep parameters and CRF have been documented in a limited number of studies, including two randomized-controlled trials using cognitive behavioural therapy for insomnia (CBT-I). In contrast, the efficacy of pharmacological therapies in reducing both insomnia and CRF is largely lacking. Clearly, treating clinically significant insomnia is likely to have benefits for the patient with cancer and for those who are recovering from cancer. In particular, pharmacotherapies for insomnia, singly or in combination with CBT-I, should be evaluated in multicentre randomized clinical trials to examine their efficacy in improving sleep quality and reducing associated CRF.

How is sleep quality affected by the psychological and symptom distress of advanced cancer patients?

The aim of this study was to assess the relationship between sleep quality, pain, psychological distress, cognitive status and post-traumatic experience in advanced cancer patients. Participants were 82 advanced cancer patients referred to a palliative care unit for control of pain and other symptoms. A variety of assessment tools were used to examine the prevalence of sleep disturbance, the severity of pain and depression, hopelessness, cognitive function and quality of life. Using the Pittsburgh Sleep Quality Index (PSQI) 96% of patients were 'poor sleepers'. Statistically significant associations were found between PSQI and the SF-12 (Short Form-12) Quality of Life Instrument (MCS, P < 0.0005, PCS, P < 0.0005), depression (Greek Depression Inventory) (P < 0.0005) and hopelessness (Beck Hopelessness Scale) (P = 0.003). Strong associations were also found between PSQI and IES-R (Impact of Event Scale-Revised) (P = 0.004). The strongest predictors of poor sleep quality in this model were MCS (P < 0.0005), PCS (P < 0.0005) and IES-R (P = 0.010). Post-traumatic experience and quality of life seemed to be the strongest predictors of sleep quality in a sample of advanced cancer patients referred for palliative care.