Impact of breast cancer treatments on sleep disturbances - A systematic review

Returning to Work after Breast Cancer: A One-Year Mixed-Methods Study

Breast cancer (BC) is the most common invasive neoplasm and affects many women of working age. The return to work (RTW) of female survivors (BCSs) is associated with a better quality of life and longer survival. A tailored intervention to promote RTW was launched in 2022. A year later, the women were contacted to find out if RTW had occurred regularly and what their health conditions were compared to the baseline. BCSs reported excessive fatigue, poor sleep quality, anxiety, depression and reduced work ability; these parameters had not improved significantly compared to the baseline. Thematic analysis of the interviews confirmed the presence of personal, company, and societal factors that could hinder or favor RTW. The interviews demonstrated that, even in an economically developed country that has provided numerous benefits for BCSs, protection is not always effective. Personalized intervention seems necessary to complete the process of reintegrating BCSs into their future working careers.

Exploration of effects of galvanic vestibular stimulation on circadian rhythms and its associations with sleep and spatial memory in patients with breast cancer: The ICANSLEEP-2 protocol

BACKGROUND

Patients with breast cancer (BC) exhibit circadian rhythm disruptions, mainly of rest-activity rhythm (RAR), of which sleep is an essential component, and cortisol rhythm. Sleep complaints such as insomnia and cognitive impairments are prevalent in BC. In general population, sleep is known to contribute greatly to cognition. Thus, improving RAR (and particularly sleep) could help limiting cognitive impairments in BC patients. It has recently been suggested that, in addition to its essential role in spatial memory, the vestibular system contributes to RAR synchronization. Its stimulation could therefore limit both sleep disturbances and spatial memory deficits in BC.

OBJECTIVES

The main aim of the ICANSLEEP-2 study is to assess the effects of galvanic vestibular stimulation (GVS) on circadian rhythms. The secondary aim is to assess whether GVS improves sleep and spatial memory in BC patients.

METHODS

Two groups with insomnia complaints (Insomnia Severity Index > 7) will be included: a patients' group with BC (n = 50) and a healthy control group without history of cancer (n = 25). There will be two assessment sessions, before and after 2 weeks of GVS. Patients will be randomly assigned to either a GVS group or a sham group (noneffective stimulation). Controls will receive GVS. GVS effects will be quantified and compared between groups. Assessments will include actigraphy, salivary cortisol, polysomnography, a cognitive test battery (including a computer-based task for spatial memory) and validated questionnaires (for psychological functioning and sleep complaints).

DISCUSSION

Current methods for improving sleep in BC have had controversial outcomes regarding sleep structure. We expect GVS to offer a new mean of directly targeting RAR disruptions in BC patients, with beneficial effects on sleep structure. Given the crucial impact of sleep on cognitive functioning, notably spatial memory, improving sleep of BC patients should enhance their cognitive functioning.

ETHICS AND DISSEMINATION

This study received ethical approval from the Ile de France IV institutional review board on 19 April 2022 (no. ID-RCB: 2022-A00437-36). The findings yielded by this protocol will be presented at various conferences and in peer-reviewed journals.

CLINICALTRIALS.GOV REGISTRATION NUMBER

NCT05414357.

Effect of music therapy combined with aerobic exercise on sleep quality among breast cancer patients undergoing chemotherapy after a radical mastectomy: a randomized controlled trial

PURPOSE

We aimed to study the effect of music therapy combined with aerobic exercise on the sleep quality of patients undergoing chemotherapy after a radical mastectomy.

METHODS

A randomized controlled trial was conducted at the Breast Disease Diagnosis and Treatment Center, Shaanxi Province Tumor Hospital, from July 2017 to June 2019. 110 female breast cancer patients who underwent a radical mastectomy were recruited and randomly allocated into an intervention group or a control group. The intervention group completed music therapy combined with aerobic exercise from the first to the sixth admission to the hospital for chemotherapy, while the control group received only routine nursing care. The sleep quality of these patients was measured using the Pittsburgh Sleep Quality Index (PSQI). A linear mixed model was used to adjust the PSQI of patients after controlling for other confounding factors.

RESULTS

The mean sleep quality score of the breast cancer patients who received chemotherapy after a radical mastectomy (baseline) was 8.86 ± 2.34. The intervention group had a significantly lower mean global PSQI score than the control group from the first test to the third test, with an adjusted mean difference of -1.05 (95%CI: -1.86, -0.24; P = 0.01), -2.89 (95%CI: -3.70, -2.08; P < 0.001) and - 4.84 (95%CI: -5.65, -4.03; P < 0.001), respectively. A change in the global PSQI score from baseline for the intervention group was from 0.55 (95%CI: -0.24, 1.34; P = 0.171) at the first test to 2.75 (95%CI: 1.96, 3.53; P < 0.001) at the last test, and for the control group was from - 0.51 (95%CI: -1.31, 0.29; P = 0.213 at the first test to -2.10 (95%CI: -2.91, -1.30; P < 0.001) at the last test.

CONCLUSIONS

An intervention of music therapy combined with aerobic exercise can significantly improve the sleep quality of female breast cancer patients undergoing chemotherapy after a radical mastectomy, and this intervention continuously improves many aspects of sleep reactivity.

CLINICAL TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100042975, 02/02/2021).

Bright light therapy has a positive effect on sleep quality in patients with cancer: A meta-analysis

Cancer patients frequently encounter difficulties associated with suboptimal sleep quality. Bright Light Therapy (BLT), an innovative treatment approach, has shown promise in enhancing sleep quality. However, several literature reviews showed conflicting results, and more analysis should be conducted regarding detailed BLT settings on sleep. This meta-analysis was undertaken to comprehensively assess the impact of BLT on sleep quality among cancer patients. Twelve studies with 679 patients were included. Compared with the control group, BLT overall resulted in significant improvements in terms of sleep quality [g = -0.34], total sleep time [g = 0.24], wake after sleep onset [g = -0.80], and fatigue [g = -0.54]. However, it did not yield a statistically significant effect on sleep efficiency, sleep onset latency, and insomnia severity. Regarding light settings, interventions featuring light intensities >5000lux, intervention duration ≥4 weeks, spectral emission peak at 464∼465 nm, and using a lightbox demonstrated heightened efficacy in improving sleep. BLT may be considered a supplementary therapeutic option to improve sleep quality among cancer patients. However, more extensive and rigorous studies are necessary to determine the optimal timing of BLT delivery and its applicability to cancer patients across different age groups.

Prevalence and predictors of sleep problems in women following a cancer diagnosis: results from the women's wellness after cancer program

PURPOSE

Using a discrete dataset from the Women's Wellness after Cancer Program (WWACP), we examine the prevalence and predictors of self-reported sleep problems in women previously treated for cancer.

METHODS

Participants were 351 women (Mage = 53.2, SD = 8.8) from the WWACP who had completed surgery, chemotherapy and/or radiotherapy for breast, gynaecological or blood cancers within the previous 24 months. Sleep problems were measured using the Pittsburgh Sleep Quality Index (PSQI). Baseline data (i.e. prior to intervention randomisation) were analysed.

RESULTS

Most women (59%) reported clinically significant sleep disturbance (PSQI > 5), 40% reported insufficient sleep duration (< 7 h), 38% self-reported poor sleep quality and 28% reported poor habitual sleep efficiency (sleep efficiency < 75%). Fewer psychological and vasomotor climacteric symptoms, age < 45 years and having a partner were associated with reduced odds (AOR < 1) of sleep problems. Higher levels of pain-related disability, and an intermediate compared to 'high' level of education, were associated with increased odds (AOR > 1) of sleep problems.

CONCLUSIONS

These findings confirm previous studies that have found a high prevalence of sleep problems in women previously treated for cancer. A range of sociodemographic, climacteric and pain-related factors were associated with sleep problems in this study.

IMPLICATIONS FOR CANCER SURVIVORS

Targeted interventions to improve sleep quality after cancer treatment should be explored in this population. Predictors identified in this study could inform intervention targeting and development.

Efficacy of acupuncture treatment for breast cancer-related insomnia: study protocol for a multicenter randomized controlled trial

Background

Insomnia is one of the most common symptoms among breast cancer patients, which can be present throughout all stages of breast cancer. As a non-pharmacological alternative treatment, acupuncture has been suggested to improve sleep situations in patients with cancer suffering from insomnia. However, there is a lack of well-designed, high-quality clinical evidence regarding the efficacy of acupuncture in the treatment of breast cancer-related insomnia. This study is conducted to evaluate the efficacy and safety of acupuncture treatment for breast cancer-related insomnia.

Methods

This study was designed as a multicenter, randomized, sham-controlled clinical trial. A total of 264 eligible patients with breast cancer-related insomnia will be randomized into an acupuncture group and a sham acupuncture group in a 1:1 ratio. In the trial, patients in the acupuncture and sham acupuncture groups will receive 12 sessions over a consecutive 4-week period. The primary outcome will be the treatment response rate of Insomnia Severity Index (ISI) at week 4; secondary outcomes include treatment remission rate of ISI, Sleep Efficiency (SE) obtained by the use of Sleep diary, treatment response rate of ISI at 8th and 16th weeks of follow-up, the mean changes of ISI, Generalized Anxiety Disorder Scale (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Quality of Life Questionnaire - Core 30 (QLQ-C30), sleep parameters recorded in Actigraphy and weekly usage of remedial drugs. Adverse events will be recorded throughout the study. All analyses will be based on the ITT principle and performed with SAS 9.4 statistical software.

Discussion

This trial will evaluate the clinical efficacy and safety of acupuncture for breast cancer-related insomnia. If proven effective, acupuncture will provide an effective option for patients with breast cancer-related insomnia, which will play a positive role in helping patients reduce their use of sleeping medications.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05510700.

Sleep disturbance among breast cancer survivors and controls from midlife to early older adulthood: Pink SWAN

PURPOSE

To compare sleep disturbance from 5 years pre- to 5 years post-diagnosis between breast cancer survivors (BCS) and women without cancer over the same period and to identify BCS subgroups exhibiting different sleep trajectories.

METHODS

Analyses included data from 152 BCS and 2163 controls from 20 years of follow-up in the longitudinal Study of Women's Health Across the Nation (SWAN), a multi-racial/ethnic cohort study. SWAN participants were assessed approximately annually from 1995 to 2015 using a standardized protocol. Pink SWAN focused on women who reported no cancer at SWAN enrollment and developed incident breast cancer after enrollment or did not develop breast cancer. Nonparametric locally weighted scatterplot smoothing plots and linear mixed models were used to compare the prevalence of the most frequently reported sleep problem, frequently waking several times a night (a sleep maintenance problem) during the previous 2 weeks, between BCS and controls in the 5 years pre- to 5 years post-diagnosis. We characterized heterogeneity among BCS on this sleep problem using group-based trajectories and examined pre-diagnosis variables as predictors of group membership.

RESULTS

No differences were found between BCS and controls in prevalence of frequent nighttime awakenings either before or after diagnosis. Among BCS, three trajectory groups were identified. Thirty-seven percent of BCS had consistently low prevalence of waking several times per night, 30% had high prevalence, and 33% had increasing prevalence which started 2 years pre-diagnosis. Prevalence of pre-diagnosis vasomotor symptoms, anxiety, depressive symptoms, and smoking differed among these groups.

CONCLUSION

Among mid-aged women diagnosed with breast cancer, this diagnosis did not trigger/amplify a sleep maintenance problem. The majority of BCS had similar levels of this sleep problem from pre- to post-diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Although sleep maintenance problems were not amplified by a cancer diagnosis, a subset of BCS may have sleep issues that should be monitored and treated, as indicated.

Sleep quality and psychological disorders in breast cancer female patients receiving radiotherapy at a tertiary oncology center in West Saudi Arabia

PURPOSE

Breast cancer is the most prevalent type of cancer among women worldwide. Many recently diagnosed and treated breast cancer patients complain about sleep disorders, depression, anxiety, stress, and fatigue. This study aimed to evaluate sleep quality among breast cancer patients and to assess its association with psychological disorders, and socio-demographic and clinical characteristics of patients.

METHODS

This cross-sectional study was conducted among women who received radiotherapy for breast cancer (stage 1-3) at King Abdul-Aziz Medical City-Jeddah from January to August 2021. Each participant completed a personal information form, the Pittsburgh Sleep Quality Index (PSQI), the Depression, Anxiety, and Stress Scale-21 (DASS-21), and the International Physical Activity Questionnaire (IPAQ). Clinical data were collected from the medical records to evaluate certain risk factors. Descriptive statistics were used for participant characteristics, and analyses of variance were used to assess associations between the qualitative variables.

RESULTS

Fifty-six women with a mean age of 50.1 years and an average of 10 months after cancer diagnosis were included. Poor sleep quality was present in 58% of respondents. Symptomatic depression, anxiety, and stress were found in 34%, 32%, and 30% of women, respectively. Poor sleep quality was associated with depression (p = 0.031), anxiety (p = 0.03), and stress (p = 0.024) and was independently associated with hot flashes. In multivariate analysis, patients with depression or with cancer for more than 6 months were less likely to have good sleep after controlling other variables (21.74 and 14.71 times, respectively).

CONCLUSION

Poor sleep quality was present in 58% of women with breast cancer receiving radiotherapy and was significantly associated with depression, anxiety, stress, and hot flashes. Depression level and cancer duration were significant predictors of sleep quality. Early identification and proper management of psychological and sleep disorders are necessary to improve the quality of life and survival of breast cancer patients.

Various types of stress and greater use of disengagement coping are associated with worse sleep disturbance in oncology patients undergoing chemotherapy

Various types of stress and the choice of coping strategies may be risk factors for higher levels of sleep disturbance in oncology patients. Purposes were to evaluate for differences in global, cancer-specific, and cumulative life stress, as well as resilience and the use of coping strategies among three subgroups of patients with distinct sleep disturbance profiles (i.e., Low, High, Very High). Oncology outpatients (n = 1331) completed measures of global (Perceived Stress Scale), cancer-specific (Impact of Event Scale-Revised), and cumulative life (Life Stressor Checklist-Revised) stress, resilience (Connor-Davidson Resilience Scale) and coping (Brief Cope) prior to their second or third cycle of chemotherapy. Sleep disturbance was assessed six times over two chemotherapy cycles. Differences were evaluated using parametric and non-parametric tests. All stress measures showed a dose response effect (i.e., as the sleep disturbance profile worsened, levels of all types of stress increased). Compared to Low class, the other two classes reported higher levels of global perceived stress and higher occurrence rates and effect from previous stressful life events. Impact of Event Scale-Revised scores for the Very High class indicated post-traumatic symptomatology. Patients in High and Very High classes had resilience scores below the normative score for the United States population and used a higher number of disengagement coping strategies. Our findings suggest that very high levels of sleep disturbance are associated with higher levels of various types of stress, lower levels of resilience, and higher use of disengagement coping strategies. Clinicians need to perform routine assessments and implement symptom management interventions to reduce stress and encourage the use of engagement coping strategies.

Social enrichment alters the response of brain leukocytes to chemotherapy and tumor development in aged mice

Aging is a risk factor for the development of breast cancer. Foundational science studies have supported associations among neuroinflammation, breast cancer, and chemotherapy, but to date, these associations are based on studies using young adult rodents. The current study examined the neuroinflammatory effects of chemotherapy in aged, tumor-naïve and tumor-bearing mice with or without social enrichment. Mice received two intravenous injections of doxorubicin (A) and cyclophosphamide (C) at a two-week interval. Brain immune cells were enriched/assessed via flow cytometry, seven days following the second chemotherapy injection. Social enrichment enhanced peripheral immune cell trafficking in aged tumor-naive mice treated with AC. Group housed aged tumor bearing mice receiving AC had reduced percentage of IL-6+ monocytes and granulocytes relative to their singly housed counterparts. Notably, group housing aged experimental mice with young cage partners significantly reduced TNF + monocytes, tumor volume, and tumor mass. These data illustrate the importance of social enrichment in attenuating neuroinflammation and are the first to demonstrate that social support with young housing partners reduces tumor growth in aged mice.

Sleep duration and mortality among breast cancer survivors in the Western New York Exposures and Breast Cancer (WEB) Study

PURPOSE

There is increasing evidence that sleep duration may affect breast cancer survival through effects on circadian function, influencing disease progression. However, further investigation of this association is needed.

METHODS

In a population-based, prospective cohort study of women from the Western New York Exposures and Breast Cancer Study, we examined mortality outcomes with invasive breast cancer identified using the National Death Index. Cox proportion hazards ratios with 95% confidence intervals were used to estimate risk of all-cause (AC) and breast cancer-specific (BC) mortality associated with self-reported usual sleep duration with adjustment for age, race/ethnicity, years of education, body mass index (BMI), menopausal status, pack-years of smoking, tumor stage, and estrogen-receptor (ER) status. We further examined associations within strata of BMI, tumor stage, menopausal status, and ER status.

RESULTS

A sample of 817 patients with breast cancer were followed for a median of 18.7 years, during which 339 deaths were reported, including 132 breast cancer-specific deaths. Those who reported shorter or longer sleep tended to have a slightly higher BMI, to be less proportionately non-Hispanic White, to report a previous history of benign breast disease, and to have consumed more alcohol during their lifetime. We found no significant associations between sleep duration and AC or BC mortality, including within stratified analyses.

CONCLUSION

Sleep duration was not associated with either AC or BC mortality including within strata of BMI, tumor stage, menopausal status, or ER status.

Effects of sleep disturbances and circadian rhythms modifications on cognition in breast cancer women before and after adjuvant chemotherapy: the ICANSLEEP-1 protocol

BACKGROUND

Many patients treated for breast cancer (BC) complain about cognitive difficulties affecting their daily lives. Recently, sleep disturbances and circadian rhythm disruptions have been brought to the fore as potential contributors to cognitive difficulties in patients with BC. Yet, studies on these factors as well as their neural correlates are scarce. The purpose of the ICANSLEEP-1 (Impact of SLEEP disturbances in CANcer) study is to characterize sleep using polysomnography and its relationship with the evolution of cognitive functioning at both the behavioral and the neuroanatomical levels across treatment in BC patients treated or not with adjuvant chemotherapy.

METHODS

ICANSLEEP-1 is a longitudinal study including BC patients treated with adjuvant chemotherapy (n = 25) or not treated with adjuvant chemotherapy (n = 25) and healthy controls with no history of BC (n = 25) matched for age (45-65 years old) and education level. The evaluations will take place within 6 weeks after inclusion, before the initiation of chemotherapy (for BC patients who are candidates for chemotherapy) or before the first fraction of radiotherapy (for BC patients with no indication for chemotherapy) and 6 months later (corresponding to 2 weeks after the end of chemotherapy). Episodic memory, executive functions, psychological factors, and quality of life will be assessed with validated neuropsychological tests and self-questionnaires. Sleep quantity and quality will be assessed with polysomnography and circadian rhythms with both actigraphy and saliva cortisol. Grey and white matter volumes, as well as white matter microstructural integrity, will be compared across time between patients and controls and will serve to further investigate the relationship between sleep disturbances and cognitive decline.

DISCUSSION

Our results will help patients and clinicians to better understand sleep disturbances in BC and their relationship with cognitive functioning across treatment. This will aid the identification of more appropriate sleep therapeutic approaches adapted to BC patients. Improving sleep in BC would eventually help limit cognitive deficits and thus improve quality of life during and after treatments.

TRIAL REGISTRATION

NCT05414357, registered June 10, 2022.

PROTOCOL VERSION

Version 1.2 dated March 23, 2022.

Risk factors for long-term arm morbidities following breast cancer treatments: A systematic review

PURPOSE

To examine the risk factors for arm morbidity following breast cancer treatments, taking a broad view of all types of physical morbidity, including prolonged pain, lymphedema, decreased range of motion, and functional limitations.

METHODS

A systematic literature review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guidelines. Studies exploring the risk factors for prolonged arm morbidity following breast cancer surgery and treatments were included. The studies were assessed independently according to pre-eligibility criteria, following data extraction and methodological quality assessment.

RESULTS

1,242 articles were identified. After removing duplicates, the full texts of 1,153 articles were examined. Sixty-nine of these articles met the criteria and were included in the review. These 69 articles identified 29 risk factors for arm morbidity following treatments for breast cancer. The risk of bias was evaluated using NIH study quality assessment tools. The studies reviewed were published between 2001 and 2021 and included a total of 22,886 patients who were followed up for between three months and 10 years.

CONCLUSIONS

The main risk factors for long-term morbidity are removal of lymph nodes from the axilla, body mass index >30, having undergone a mastectomy, the stage of the disease, radiation therapy, chemotherapy, infection and trauma to the affected arm after surgery. An understanding of the risk factors for prolonged arm morbidity after surgery can help doctors and therapists in making personalized decisions about the need and timing of rehabilitation treatments.

Global prevalence of sleep disturbances among breast cancer survivors: A systematic review with meta-analysis

Breast cancer is a common cancer in which patients are highly susceptible to different sleep disturbances. However, current evidence lacked consistency in methodologies in investigating the prevalence of sleep disturbances among breast cancer survivors. The review aims to (1) investigate the global prevalence of sleep disturbances among breast cancer survivors; and (2) investigate the factors influencing the prevalence estimates. A comprehensive search was conducted in 8 databases using a 3-step approach, up to January 2022. The Newcastle-Ottawa Scale and Cochrane risk of bias tool were used to evaluate the quality of individual studies. Meta-analysis, meta-regression, and subgroup analysis were performed using R software. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations criteria. A total of 51 studies were selected involving 28,036 breast cancer survivors across 17 countries. The global prevalence of poor sleep quality was 62%, different severities of insomnia were 3%-32%, and excessive daytime sleepiness was 24%. Subgroup analyses showed that a significantly higher prevalence of poor sleep quality was found in breast cancer survivors during treatment compared with pre- or post-treatment. No significant covariates were found in a series of meta-regression analyses. The majority (73.5%) of individual studies were high quality but the certainty of the evidence was low or very low according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. More than half of breast cancer survivors have sleep disturbances, so developing a strategic intervention is warranted. Given the low or very low certainty of the evidence, a robust design for large-scale research is crucial in the future.

Supporting Return to Work after Breast Cancer: A Mixed Method Study

Breast cancer (BC) is the most common invasive cancer in the world. Most BC survivors (BCSs) continue working while dealing with cancer-related disabilities. BCSs' return-to-work (RTW) after cancer treatment is an important stage of their recovery and is associated with a higher survival rate. In this study, we addressed the RTW of BCSs with the intention of facilitating this process through direct action in the workplace. Thirty-two women who requested assistance from January to December 2022 were enrolled in the study. Semi-structured interviews and medical examinations were conducted by a team of three physicians. Interviews were analyzed using Thematic Analysis. Moreover, a quantitative cross-sectional study was conducted to compare the health status of BCSs with that of a control group of 160 working women, using standardized questionnaires on work ability, fatigue, sleep problems, anxiety, depression, and happiness. BCSs were also asked to rate the level of organizational justice they perceived at work prior to their illness. From the qualitative analysis emerged three facilitating/hindering themes: (1) person-related factors, (2) company-related factors, and (3) society-related factors. In the quantitative analysis, BCSs had significantly higher scores for anxiety, depression, sleep problems and fatigue, and lower levels of happiness than controls. The RTW of BCSs entails adapting working conditions and providing adequate support. The work-related analysis of each case made it possible to highlight the measures that need to be taken in the workplace to promote RTW. The treatment of cancer should be paired with advice on the best way to regain the ability to work.

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.

A randomized trial to evaluate the effects of a supervised exercise program on insomnia in patients with non-metastatic breast cancer undergoing chemotherapy: design of the FATSOMCAN study

BACKGROUND

Up to 70% of breast cancer patients report symptoms of insomnia during and after treatment. Despite the ubiquity of insomnia symptoms, they are under-screened, under-diagnosed and poorly managed in breast cancer patients. Sleep medications treat symptoms but are ineffective to cure insomnia. Other approaches such as cognitive behavioral therapy for insomnia, relaxation through yoga and mindfulness are often not available for patients and are complex to implement. An aerobic exercise program could be a promising treatment and a feasible option for insomnia management in breast cancer patients, but few studies have investigated the effects of such a program on insomnia.

METHODS

This multicenter, randomized clinical trial evaluate the effectiveness of a moderate to high intensity physical activity program (45 min, 3 times per week), lasting 12 weeks, in minimizing insomnia, sleep disturbances, anxiety/depression, fatigue, and pain, and in enhancing cardiorespiratory fitness. Patients with breast cancer be recruited from six hospitals in France and randomly allocated to either the "training" or the "control" group. Baseline assessments include questionnaires [Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index questionnaire (PSQI), Hospital Anxiety Depression Scale (HADS), Epworth Sleepiness Scale (ESS)], home polysomnography (PSG), and 7-day actigraphy coupled with completion of a sleep diary. Assessments are repeated at the end of training program and at six-month follow-up.

DISCUSSION

This clinical trial will provide additional evidence regarding the effectiveness of physical exercise in minimizing insomnia during and after chemotherapy. If shown to be effective, exercise intervention programs will be welcome addition to the standard program of care offered to patients with breast cancer receiving chemotherapy.

TRIAL REGISTRATION

National Clinical Trials Number (NCT04867096).

Non-pharmaceutical interventions in complementary and alternative medicine for insomnia in breast cancer survivors: a protocol for a systematic review and network meta-analysis

INTRODUCTION

Insomnia has a high incidence in patients with breast cancer, which not only affects the quality of life of patients, but also affects the efficiency of later treatment and rehabilitation. Although the sedative and hypnotic drugs commonly used in clinical practice have a rapid onset of action, they are also accompanied by different degrees of sequelae, withdrawal effects and dependence and addiction. Complementary and alternative medicine (CAM) or complementary and integrative medicine, complementary integrative therapies, including natural nutritional supplement therapy, psychotherapy, physical and mental exercise, physiotherapy, have been reported to be used to treat cancer-related insomnia. Its clinical results are increasingly recognised and accepted by patients. However, the effectiveness and safety of these CAM are uneven, and there is no standard clinical application method. Therefore, in order to objectively evaluate the effects of different non-pharmaceutical interventions in CAM on insomnia, we will conduct a network meta-analysis (NMA) to explore the effects of different CAM interventions on improving sleep quality in patients with breast cancer.

METHODS AND ANALYSIS

We will search all Chinese and English databases from the inception of the database to 31 December 2022. The databases include PubMed, Medline, Embase, Web of Science and Cochrane Central Register of Controlled Trials and the Chinese literature databases include CBM, CNKI, VIP, WANFANG. The Insomnia Severity Index and the Pittsburgh Sleep Quality Index will be considered as the primary outcomes in the study. STATA V.15.0 software will be used to conduct pairwise meta-analysis and NMA. Finally, we will use the recommended risk assessment tool RoB2 for risk and bias assessment, and use the Grading of Recommendations Assessment, Development and Evaluation evaluation method to evaluate the quality of evidence.

ETHICS AND DISSEMINATION

Ethical approval will not be required because the study will not include the original information of participants. The results will be published in a peer-reviewed journal or disseminated in relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022382602.

Optimising psychological treatment for pain after breast cancer: a factorial design study protocol in Denmark

INTRODUCTION

One in five breast cancer (BC) survivors are affected by persistent pain years after completing primary treatment. While the efficacy of psychological interventions for BC-related pain has been documented in several meta-analyses, reported effect sizes are generally modest, pointing to a need for optimisation. Guided by the Multiphase Optimization Strategy, the present study aims to optimise psychological treatment for BC-related pain by identifying active treatment components in a full factorial design.

METHODS AND ANALYSIS

The study uses a 2×3 factorial design, randomising 192 women with BC-related pain (18-75 years) to eight experimental conditions. The eight conditions consist of three contemporary cognitive-behavioural therapy components, namely: (1) mindful attention, (2) decentring, and (3) values and committed action. Each component is delivered in two sessions, and each participant will receive either zero, two, four or six sessions. Participants receiving two or three treatment components will be randomised to receive them in varying order. Assessments will be conducted at baseline (T1), session by session, every day for 6 days following the first session in each treatment component, at post-intervention (T2) and at 12-week follow-up (T3). Primary outcomes are pain intensity (Numerical Rating Scale) and pain interference (Brief Pain Inventory interference subscale) from T1 to T2. Secondary outcomes are pain burden, pain quality, pain frequency, pain catastrophising, psychological distress, well-being and fear of cancer recurrence. Possible mediators include mindful attention, decentring, and pain acceptance and activity engagement. Possible moderators are treatment expectancy, treatment adherence, satisfaction with treatment and therapeutic alliance.

ETHICS AND DISSEMINATION

Ethical approval for the present study was received from the Central Denmark Region Committee on Health Research Ethics (no: 1-10-72-309-40). Findings will be made available to the study funders, care providers, patient organisations and other researchers at international conferences, and published in international, peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT05444101).

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.

Association of lower extremity lymphedema with pelvic floor functions, sleep quality, kinesiophobia, body image in patients with gynecological cancers

The aim was to investigate the relationship between lower extremity lymphedema and pelvic floor functions, sleep quality, kinesiophobia, body image in patients with gynecological cancer the effect of lymphedema severity on pelvic floor dysfunction (PFD), sleep quality, fear of movement, and body image in patients with lower extremity lymphedema after gynecologic cancer. A total of 103 patients (52 patients with lymphedema and 51 patients without lymphedema) after gynecologic cancer surgery were included in March-June 2022. Bilateral circumferential measurements were taken with a tape measure at different levels to create groups. These measurements determined limb volumes by summing segment volumes derived from the truncated cone formula. For data collection, all patients were presented with the Gynecologic Cancer Lymphedema Questionnaire (GCLQ), the Global Pelvic Floor Bother Questionnaire (GPFBQ), the Pittsburgh Sleep Quality Index (PSQI), the Tampa Scale of Kinesiophobia (TSK) and the Body Image Scale (BIS) one time. The severity of lymphedema symptoms was quite high in patients with lymphedema (GCLQ Total: 13.6) (p < .05). Patients with lymphedema had higher GCLQ total scores, GPFBQ1 (stress urinary incontinence), GPFBQ4 (urge urinary incontinence), GPFBQ8 (fecal incontinence), kinesiophobia and, body image scores than patients without lymphedema (p < .05). The sleep quality levels of patients with lymphedema and patients without lymphedema were similar (p > .05). A significant negative correlation was found between GLCQ total score and body image (p < .05). There was a positive correlation between kinesiophobia and pelvic floor symptoms and a negative correlation between kinesiophobia and body image (p < .05). In this study, it was observed that in patients who developed lymphedema after gynecologic cancer surgery, pelvic floor symptoms and kinesiophobia increased and the severity of lymphedema negatively affected body image. Reducing lymphedema in these patients may improve pelvic floor health, mobility, and body image.

Adaptive Auricular Point Acupressure for Sleep Disturbance in Women with Breast Cancer: A Randomized Controlled Trial

Objectives

The study aimed to evaluate the preliminary effect and efficacy of auricular point acupressure (APA) on the quality of sleep in women with breast cancer who were undergoing chemotherapy. Sample & Setting. We conducted a randomized controlled trial on 68 patients with breast cancer who reported poor sleep quality based on the Pittsburgh Sleep Quality Index (PSQI) scores (>7). Methods & Variables. Participants were randomly assigned to an APA treatment group or a control group. Patients in the APA group had magnetic pellets attached to selected auricular points and were instructed to apply pressure to these points 4×/day for three consecutive weeks. We objectively measured sleep quality using the Actiwatch Spectrum and the PSQI at the baseline and postintervention. Statistical analyses of changes in sleep data were performed using the t-test, a rank-sum test, and analyses of covariance.

Results

In patients treated with APA, the PSQI total score and sleep onset latency had significantly decreased, while the total sleep time and sleep efficiency had significantly increased. Although the total PSQI score differed between groups at the baseline, ANCOVA results showed that the APA group had a significantly lower total PSQI score.

Conclusion

APA could be an inexpensive and effective approach to improving sleep quality and reducing sleep disturbance in patients with breast cancer. Further research needs a larger sample size to verify our findings.

The sleep, cancer and rest (SleepCaRe) trial: Rationale and design of a randomized, controlled trial of cognitive behavioral and bright light therapy for insomnia and fatigue in women with breast cancer receiving chemotherapy

BACKGROUND

Insomnia and fatigue symptoms are common in breast cancer. Active cancer treatment, such as chemotherapy, appears to be particularly disruptive to sleep. Yet, sleep complaints often go unrecognised and under treated within routine cancer care. The abbreviated delivery of cognitive behavioral therapy for Insomnia (CBTI) and bright light therapy (BLT) may offer accessible and cost-effective sleep treatments in women receiving chemotherapy for breast cancer.

METHODS

The Sleep, Cancer and Rest (SleepCaRe) Trial is a 6-month multicentre, randomized, controlled, 2 × 2 factorial, superiority, parallel group trial. Women receiving cytotoxic chemotherapy for breast cancer at tertiary Australian hospitals will be randomly assigned 1:1:1:1 to one of four, non-pharmacological sleep interventions: (a) Sleep Hygiene and Education (SHE); (b) CBTI; (c) BLT; (d) CBT-I + BLT combined and simultaneously delivered. Each sleep intervention is delivered over 6 weeks, and will comprise an introductory session, a mid-point phone call, and regular emails. The primary (insomnia, fatigue) and secondary (health-related quality of life, rest activity rhythms, sleep-related impairment) outcomes will be assessed via online questionnaires at five time-points: baseline (t0, prior to intervention), mid-point intervention (t2, Week 4), post-intervention (t3, Week 7), 3-months (t4, Week 18), and 6-months follow-up (t5, Week 30).

CONCLUSIONS

This study will report novel data concerning the comparative and combined efficacy of CBT-I and BLT during chemotherapy. Findings will contribute to the development of evidence-based early sleep and fatigue intervention during chemotherapy for breast cancer. Clinical trial information Registered with the Australian New Zealand Clinical Trials Registry (http://anzctr.org.au/), Registration Number: ACTRN12620001133921.

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

Introduction

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

Aims

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

Methods

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

Results

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

Conclusion

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

The relationship between sleep and weight change among women diagnosed with breast cancer participating in the Women's Health Initiative

PURPOSE

Short and long sleep duration and poor sleep quality are risk factors for weight gain and cancer mortality. The purpose of this study is to investigate the relationship between sleep and weight change among postmenopausal breast cancer survivors.

METHODS

Women participating in the Women's Health Initiative who were diagnosed with incident breast cancer between year one and year three were included. Self-reported sleep duration was categorized as ≤ 5 h (short), 6 h, 7-8 h (optimal), and ≥ 9 h (long). Self-reported sleep quality was categorized as poor, average, and above average. Post-diagnosis weight change was the difference of weight closest to, but preceding diagnosis, and year 3 weight. We used linear regression to evaluate sleep duration and sleep quality associations with post-diagnosis weight change adjusted for potential confounders.

RESULTS

Among 1156 participants, 63% were weight stable after diagnosis; average weight gain post cancer diagnosis was 3.2 kg. Six percent of women reported sleeping ≤ 5 h, 26% reported 6 h, 64% reported 7-8 h, and 4% reported ≥ 9 h. There were no differences in adjusted estimates of weight change among participants with short duration (0.37 kg; 95% CI - 0.88, 1.63), or long duration (- 0.56 kg; 95% CI - 2.03, 0.90) compared to optimal duration, nor was there a difference among poor quality (- 0.51 kg; 95% CI - 1.42, 0.41) compared to above average quality.

CONCLUSION

Among postmenopausal breast cancer survivors, sleep duration and quality were not associated with weight change after breast cancer diagnosis. Future studies should consider capturing change in adiposity and to expand beyond self-reported sleep.

Prostate Cancer and Sleep Disorders: A Systematic Review

Simple Summary

Longer survival times for prostate cancer patients due to efficient treatments consisting of local radiotherapy, prostatectomy and androgen-deprivation therapy, as well as androgen-receptor-targeted agents, increases the importance of side effect management. Sleep disturbances are higher in this group than the general population and no clear mechanism(s) explains this. This systematic review finds a reported effect in 14 of 16 included studies on sleep quality changes for these patients. All reported treatments showed some kind of negative effect on sleep quality, including ADT. Limitations are discussed and recommendations made for progressing the understanding and then for mitigation strategies of these side effects.

Abstract

Prostate cancer (PCa) treatment involves multiple strategies depending on the disease’s stage. Androgen deprivation therapy (ADT) remains the gold standard for advanced and metastatic stages. Sleep quality has been suggested as being additionally influenced also by local radiotherapy, prostatectomy and androgen-receptor (AR)-targeted agents. We performed a systematic review exploring the landscape of studies published between 1 January 1990 and 31 July 2021, investigating sleep disturbances in PCa patients receiving active treatments, including the influence of hormonal therapy on sleep quality as a factor affecting their quality of life. Out of 45 articles identified, 16 studies were selected, which recruited patients with PCa, undergoing active treatment in either a prospective longitudinal or cross-sectional study. Development of sleep disorders or changes in sleep quality were reported in 14 out of 16 trials included. Only five trials included objective measurements such as actigraphy, mostly at one time point and without a baseline assessment. Limitations to be addressed are the small number of existing trials, lack of randomized trials and heterogeneity of methodologies used. This systematic review outlines the lack of prospective trials investigating sleep disorders, with a rigorous methodology, in homogeneous cohorts of PCa patients. Future trials are needed to clarify the prevalence and impact of this side effect of PCa treatments.

Sleep and health-related quality of life in women following a cancer diagnosis: results from the Women's Wellness after Cancer Program in Australia

PURPOSE

Sleep disturbance after cancer treatment could compromise recovery. This paper examined the associations between post-treatment sleep problems and health-related quality of life (HRQoL), and the effectiveness of an e-enabled lifestyle intervention on sleep outcomes.

METHODS

The Women's Wellness after Cancer Program (WWACP) was examined in a single blinded, multi-centre randomised controlled trial. Data were collected from 351 women (M_age = 53.2, SD = 8.8; intervention n = 175, control group n = 176) who had completed surgery, chemotherapy and/or radiotherapy for breast, gynaecological or blood cancers within the previous 24 months. Participants completed the Pittsburgh Sleep Quality Index (PSQI) at baseline (prior to intervention randomisation), and at 12 and 24 weeks later. Sociodemographic information, menopausal symptoms (Greene Climacteric Scale) and HRQoL (36-Item Short Form Health Survey; SF-36) were also collected. Linear panel regression was used to examine the association between sleep variables and SF36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. A difference-in-difference regression model approach was used to examine the intervention effect on the sleep outcomes.

RESULTS

After adjustment for potential confounders, the sleep variables (except sleep duration) significantly predicted physical, but not mental, HRQoL. There was no statistically significant effect of the intervention on sleep outcomes at 12 or 24 weeks.

CONCLUSION

Women who have completed treatment for cancer experience sleep problems that are associated with decreased physical HRQoL. Improving sleep through targeted interventions should improve their physical HRQoL. Improved targeting of the sleep components of the WWACP should be explored.

Cancer as a tool for preclinical psychoneuroimmunology

Cancer represents a novel homeostatic challenge to the host system. How the brain senses and responds to changes in peripheral physiology elicited by tumor growth is a largely untapped area of research. This is especially relevant given the widespread prevalence of systemic problems that people with various types of cancer experience. These include disruptions in sleep/wake cycles, cognitive function, depression, and changes in appetite/food intake, among others. Critically, many of these problems are evident prior to diagnosis, indicating that their etiology is potentially distinct from the effects of cancer treatment or the stress of a cancer diagnosis. Psychoneuroimmunology (PNI) is well equipped to tackle these types of problems, as it uses approaches from multiple disciplines to understand how specific stimuli (endogenous and environmental) are transduced into neural, endocrine, and immune signals that ultimately regulate health and behavior. In this article, I first provide a brief historical perspective of cancer and PNI, introduce the idea of cancer as a systemic homeostatic challenge, and provide examples from preclinical literature supporting this hypothesis. Given the rise of advanced tools in neuroscience (e.g., calcium imaging), we can now monitor and manipulate genetically defined neural circuits over the extended time scales necessary to disentangle distal communication between peripheral tumors and the brain.

Insomnia and Fatigue Symptom Trajectories in Breast Cancer: A Longitudinal Cohort Study

Objective: Insomnia and fatigue are common, although not inevitable, during breast cancer. This study is one of the first aiming to describe distinct trajectory classes of insomnia and fatigue symptoms, and their correlates, from diagnosis through treatment.Methods: This longitudinal cohort study was conducted at a comprehensive cancer center and community oncology practices. Participants (N = 460) were women diagnosed with any stage of breast cancer in the previous 4 months. Primary outcomes for this ancillary study of the existing cohort were self-reported insomnia and fatigue symptoms assessed repeatedly across 12 months.Results: Four distinct classes of insomnia symptoms emerged: persistently very high, clinically elevated symptoms (13.7%); high, clinically elevated symptoms (65.9%); stable low (17.2%) or very low (2.6%) symptoms. Five fatigue symptom classes included high, increasing fatigue (9.6%), two recovery classes starting at high (26.3%), or moderate (18.0%) severity at diagnosis, stable low (33.3%) or very low (12.2%) classes. In multivariate analyses, higher depressive symptoms, anxiety, and chronic life stress were associated with being in the very high insomnia class versus the low symptom class. Oncologic factors were not associated with insomnia class membership. Receiving chemotherapy was linked significantly to high and recovery fatigue symptom classes versus the low class. Higher chronic life stress was associated with more persistent fatigue symptoms.Conclusions: Distinct classes of insomnia and fatigue symptoms were evident; 79.6% of the women had clinically elevated, persistent insomnia symptoms, 53.9% had elevated fatigue. A substantial minority evidenced low symptoms, suggesting targeted or stepped-care approaches to symptom management.

Rest activity rhythms characteristics of breast cancer women following endocrine therapy

Rest-activity rhythm (RAR) disruptions are frequently associated with chemotherapy in breast cancer (BC), but they are less known in BC with endocrine therapy. The aim of this ancillary study was to characterize the RAR and estimated sleep characteristics from actigraphy in BC patients either treated (ET+) or untreated with endocrine therapy (ET-), compared to healthy controls (HC) and using a cross-sectional design. Eighteen ET+, 18 ET- and 16 HC completed questionnaires and wore wrist actigraphs at home for 2 weeks. Parametric and non-parametric RAR, sleep parameters, and quality of life were compared between groups (p<0.05). BC groups presented lower daytime activity than HC according to RAR analysis (mesor and M10 parameters). Compared to HC, ET- had lower inter-daily stability and ET+ had greater sleep complaints. Compared to ET-, ET+ had lower sleep efficiency, more time awake and higher activity levels at night, as assessed with actigraphy. Our results suggest an effect of cancer independent of treatment on RAR in BC, highlighting the need for further investigation of this topic. In contrast, sleep as assessed with actigraphy seems modified only during ET which matches with patients' sleep complaints. Further longitudinal studies would aid in confirming the latter hypothesis.

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

STUDY OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical and Genetic Factors Associated With the Breast Cancer-Related Sleep Disorders: The "CAGE-Sleep" Study-A Cross-Sectional Study

CONTEXT

Despite being among the most reported concerns in breast cancer patients, sleep disturbances are still poorly assessed and managed in routine clinical practice. Correctly evaluating these symptoms and understanding the underlying clinical and genetic factors would help medical teams develop an adequate treatment strategy for each patient.

OBJECTIVES

1) To explore the severity of insomnia as well as sleep quality in a sample of Lebanese women with breast cancer undergoing chemotherapy; 2) To examine the correlation between sociodemographic, clinical, psychiatric (anxiety and depression), genetic factors, and alterations in sleep patterns.

METHODS

A cross-sectional study was carried out using the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) (December 2017-June 2019; Ethical reference number: CEHDF1016). All patients gave their written consent and were genotyped for several polymorphisms in CLOCK, CRY2, PER2, COMT, DRD2, OPRM1, and ABCB1 genes using Lightcycler® (Roche).

RESULTS

Our sample included a total of 112 women. Almost half of the patients reported insomnia problems (with 20.5% moderate insomnia and 7.1% severe insomnia). Multivariable analyses taking the PSQI score as the dependent variable, showed that higher depression score and dyslipidemia (yes versus no) were significantly associated with higher PSQI scores (worse sleep quality), whereas having the DRD2 CT genotype versus CC and a higher chemotherapy cycle number were significantly associated with lower PSQI scores (better sleep quality). Depression was also significantly associated with higher ISI scores. When forcing all the genes in each model, the results remained the same except for depression that has been replaced by anxiety in the multivariable analysis.

CONCLUSION

Our study confirms the relationship between anxiety/depression, cycle number, dyslipidemia and DRD2 polymorphism with insomnia and highlights the importance of treating all associated factors to improve the overall QOL of patients.

Are Sleep Complaints Related to Cognitive Functioning in Non-Central Nervous System Cancer? A Systematic Review

Patients with non-central nervous system (CNS) cancer frequently report cognitive complaints, that are recurrent and affect their quality of life. In order to improve supportive care of these cognitive difficulties, it is important to identify associated factors. Sleep disturbance is a good candidate to study, as patients with non-CNS cancer frequently report sleep disorders, and sleep plays a key role in cognitive functioning. The objective of the present systematic review was to summarize the results of studies evaluating the relationship between cognition and sleep in non-CNS cancer, and to highlight the need for further studies. PubMed [Medline] and Scopus databases were screened from April to November 2020 for studies published in English evaluating the association between cognition and sleep in adults with non-CNS cancer. The characteristics and risk of bias for each of the 30 included studies have been reported. Greater cognitive complaints in patients with non-CNS cancer were related to poorer self-reported sleep quality in almost all studies (n = 22/24). By contrast, around half of the studies reported a significant association between poorer neuropsychological performances and sleep complaints (n = 5/11). The studies were found to have several limitations, such as the lack of a control group, which would have shed the light on the period of occurrence of this association (e.g. after cancer diagnosis or after cancer treatments). Our review also identified factors that may influence the relationship between cognition and sleep. Recommendations are given for improving the methodology of future studies and extending the impact of their results.

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.

Sleep and endocrine therapy in breast cancer

Sleep disturbances and insomnia are common among breast cancer survivors, and can have a significant effect on quality of life and numerous other significant outcomes. Among risks for sleep disturbance is the introduction of anti-estrogen endocrine therapies. The possible contributing factors to sleep disturbance in endocrine therapy are complex, and include pre-existing sleep disorders, the effects of chemotherapy and other treatments, and concurrent symptoms such as hot flashes. In addition, sleep disturbance in menopause, the natural downregulation of reproductive hormones in older age, is a common occurrence, and can offer a model for understanding the high prevalence of sleep problems in breast cancer survivors on endocrine therapy, as well as suggesting possible treatments such as behavioral interventions and pharmaceuticals. Altogether, significantly more research is needed to better understand and address sleep disturbance in breast cancer survivors on endocrine therapy in order to support quality of life and treatment adherence.

Biological Rhythm and Chronotype: New Perspectives in Health

The circadian rhythm plays a fundamental role in regulating biological functions, including sleep–wake preference, body temperature, hormonal secretion, food intake, and cognitive and physical performance. Alterations in circadian rhythm can lead to chronic disease and impaired sleep. The circadian rhythmicity in human beings is represented by a complex phenotype. Indeed, over a 24-h period, a person’s preferred time to be more active or to sleep can be expressed in the concept of morningness–eveningness. Three chronotypes are distinguished: Morning, Neither, and Evening-types. Interindividual differences in chronotypes need to be considered to reduce the negative effects of circadian disruptions on health. In the present review, we examine the bi-directional influences of the rest–activity circadian rhythm and sleep–wake cycle in chronic pathologies and disorders. We analyze the concept and the main characteristics of the three chronotypes.

The Relationship between Fatigue and Actigraphy-Derived Sleep and Rest-Activity Patterns in Cancer Survivors

Cancer-related fatigue can continue long after curative cancer treatment. The aim of this study was to investigate sleep and rest–activity cycles in fatigued and non-fatigued cancer survivors. We hypothesized that sleep and rest–activity cycles would be more disturbed in people experiencing clinically-relevant fatigue, and that objective measures of sleep would be associated with the severity of fatigue in cancer survivors. Cancer survivors (n = 87) completed a 14-day wrist actigraphy measurement to estimate their sleep and rest–activity cycles. Fatigue was measured using the Functional Assessment of Chronic Illness Therapy Fatigue Scale (FACIT-F). Participants were dichotomised into two groups using a previously validated score (fatigued n = 51 and non-fatigued n = 36). The participant’s perception of sleep was measured using the Insomnia Severity Index (ISI). FACIT-F score was correlated with wake after sleep onset (r = −0.28; p = 0.010), sleep efficiency (r = 0.26; p = 0.016), sleep onset latency (r = −0.31; p = 0.044) and Insomnia Severity Index (ISI) score (r = −0.56; p < 0.001). The relative amplitude of the rest–activity cycles was lower in the fatigued vs. the non-fatigued group (p = 0.017; d = 0.58). After treatment for cancer, the severity of cancer-related fatigue is correlated with specific objective measures of sleep, and there is evidence of rest–activity cycle disruption in people experiencing clinically-relevant fatigue.

Sleep disturbance among Arabic breast cancer survivors

BACKGROUND

Sleep disturbance is the most common and distressing cancer symptom that negatively affects the quality of life (QoL). The main objective of this study is to determine the prevalence of sleep disturbance among Arabic women with breast cancer, post-treatment, and assess their sleep disturbance in relation to health-related QoL, demographics and treatment characteristics.

METHODS

In this study, cross-sectional data were collected using the Pittsburgh Sleep Quality Index (PSQI: 19-items) and the Functional Assessment of Cancer Therapy-General (FACT-G: 27 items). Demographic information and treatment characteristics were also collected.

RESULTS

A total of 133 women who had been diagnosed with breast cancer agreed to participate in the study. Approximately three-quarters (73.7%; n = 98) of the participants was reported as poor sleepers (PSQI ˃ 5). The worse mean score of the PSQI component was the sleep latency with the highest score (M = 1.71, SD = 0.93). There were significant relationships between poor sleep and treatment (patients receiving both chemotherapy and radiotherapy) and with comorbidities (asthma, anaemia, hypertension/heart failure, diabetes/heart diseases) (P < 0.05). Those experiencing poor sleep had the lowest QoL among the cancer patients.

CONCLUSION

Sleep disturbance is a significant problem for Arabic patients diagnosed with breast cancer. The result suggests that sleep disturbance should be routinely assessed in clinical settings. Further research should develop an intervention for management to reduce sleep disturbance and improve sleep quality in cancer patients.

Feasibility of a Preventive Intervention for Insomnia in Women with Breast Cancer Receiving Chemotherapy

Objective/Background: Breast cancer patients display high rates of insomnia and chemotherapy treatments appear to contribute significantly to the development of sleep disturbances among this population. The efficacy of cognitive-behavioral therapy for insomnia (CBT-I) is now well established for treating insomnia comorbid with cancer but is not widely accessible and is also fairly costly. Its capacity to prevent the onset of insomnia symptoms in cancer patients who are at a high risk of developing these difficulties remains to be demonstrated. The purpose of this study was to assess the feasibility of a brief self-administered preventive intervention of insomnia in breast cancer patients about to undergo chemotherapy. Participants/Methods: A sample of 20 women with breast cancer and with no insomnia were recruited and received the preventive intervention, taking the form of a short booklet, at their first chemotherapy treatment. One month later, a semi-structured phone interview was conducted to assess their satisfaction with different aspects of the booklet (e.g., format, content) and their adherence to the proposed strategies and to collect qualitative information. A 3-month follow-up evaluation was also conducted. Results: Patients reported a higher level of satisfaction than expected (mean score corresponding to "a lot" on the scale) and a moderate level of adherence falling only slightly under the hypothesized level. The open comments collected corroborated the good acceptability of this minimal preventive CBT-I in breast cancer patients initiating chemotherapy. Conclusions: Overall, findings of this study confirm that a self-administered preventive intervention for insomnia is feasible and a promising approach in breast cancer patients about to initiate chemotherapy.

The efficacy and mechanisms of a guided self-help intervention based on mindfulness in patients with breast cancer: A randomized controlled trial

BACKGROUND

Mindfulness-based interventions (MBIs) can alleviate psychological distress in patients with cancer. However, face-to-face MBIs may be inconvenient for patients. Therefore, guided self-help interventions may be more accessible. The authors investigated the effects of a guided self-help MBI for depression, anxiety, and sleep disorder symptoms in patients with breast cancer and explored the potential underlying mechanisms.

METHODS

One hundred forty-four postoperative patients with breast cancer were randomly assigned to an intervention group (6-week guided self-help MBI; n = 72) or a wait-list control group (routine treatment; n = 72). Self-reported depression, anxiety, sleep disorder symptoms, and rumination and worry as potential mediators were assessed at baseline and postintervention. Outcomes were then assessed at 1-month and 3-month follow-up. The intervention's effects over time and the potential mediating effect were analyzed using generalized estimating equations. The trial was registered at the Chinese Clinical Registry (ChiCTR-IOR-16008073).

RESULTS

Significant improvements in depression and sleep disorder symptoms occurred in the intervention group compared with wait-list controls, and the improvements were maintained at 1-month and 3-month follow-up. Changes in rumination and worry mediated the intervention's effects on changes in depression and sleep disorder symptoms.

CONCLUSIONS

A guided self-help MBI reduced depressive and sleep disorder symptoms by mitigating rumination and worry in patients with breast cancer. These findings support benefits of this accessible psychological intervention in oncology and provide insight into possible mechanisms of action. The current research contributes to discovering effective and widely accessible means for people with physical health conditions and may remove barriers that otherwise would have precluded participation in face-to-face psychological interventions.

Chemotherapy-Induced Peripheral Neurotoxicity as A Risk Factor for Poor Sleep Quality in Breast Cancer Survivors Treated with Docetaxel

Objective:

The purpose of this study was to explore sleep quality and to determine whether chemotherapy-induced peripheral neurotoxicity is a risk factor for poor sleep quality in breast cancer survivors who receive docetaxel treatment.

Methods:

Secondary data analysis from a cross-sectional study. Sample characteristics were collected using an information sheet. Independent variables included the Hospital Anxiety and Depression Scale (HADS), the Patient Neurotoxicity Questionnaire (PNQ), and the Identification Pain Questionnaire (ID pain). Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI). We performed descriptive analyses and simple logistic regression.

Results:

A total of 98 participants were included. More than 60% of them reported poor sleep quality, with their average PSQI score being 7.54 ± 4.45. Poor subjective sleep quality (1.37 ± 0.88) and short sleep duration (1.37 ± 1.08) were their main problems. In addition, significant risk factors for poor sleep quality were chronic illness (odds ratio [OR] = 2.753, P = 0.041), anxiety (OR = 7.714, P = 0.009), neuropathic pain (OR = 11.261, P = 0.022), sensory neuropathy (OR = 2.529, P = 0.032), motor neuropathy (OR = 3.781, P = 0.002), and undergoing chemotherapy (OR = 2.593, P = 0.027). Targeted therapy that some survivors received served as a protective factor (OR = 0.351, P = 0.015).

Conclusions:

We found a high prevalence of poor sleep quality in breast cancer survivors treated with docetaxel. The results indicated that, in addition to clinical characteristics and psychological discomfort, chemotherapy-induced peripheral neurotoxicity is a significant risk factor for poor sleep quality.

The effect of cognitive behavioral therapy on the quality of life of breast cancer patients: a systematic review and meta-analysis of randomized controlled trials

PURPOSE

Several lines of clinical research support the efficacy of Cognitive behavioral therapy (CBT) with a large number of population and various disease conditions, however, the true effects of CBT interventions on Quality of Life of breast cancer patients remain unknown. The aim of the study was to evaluate the effect of Cognitive Behavioral Therapy on the Quality of Life of breast cancer patients.

METHODS

A systematic review of articles published using Web of Science (1950-January 2020); Medline via EBSCO (1992-January 2020); Science direct via ELSEVIER (1996-January 2020); SCOPUS (2004-January 2020); and PubMed (1946-January 2020 excluding Medline from 1992-January 2020) were included. Additional studies were included after  checking reference lists of all relevant studies; searching ongoing trials and research registers and manual search. Data extraction was conducted by two independent authors and a third independent author checked the data extraction. The PRISMA statement was adopted.

RESULT

Eleven Randomized controlled trials (RCT) with 1690 breast cancer patients were included in this review. The overall effect size of cognitive behavioral therapy on QoL of breast cancer patients was medium 0.39 (95% CI 0.12-0.66, P < 0.00001, I² = 83%). Five studies had shown statistically significant improvement in functional and symptoms scales in the treatment group than the control group.

CONCLUSION

CBT is effective in improving the Quality of Life of breast cancer patients. In future research, further randomized controlled trials with adequate randomization, allocation concealment, and appropriate blinding may be needed.

Sleep quality and mental health in the context of COVID-19 pandemic and lockdown in Morocco

BACKGROUND

The lockdown of COVID-19 (Coronavirus Disease 2019) is associated with several stressful factors that can negatively affect peoples' sleep quality and mental health.

OBJECTIVES

We conducted this study to evaluate sleep disorders and psychological impact associated with the spread of the COVID-19 and the lockdown on the Moroccan population. We also aimed to study the effects of respondents' beliefs and attitudes about sleep on sleep disorders, anxiety-related symptoms, and depressive symptoms.

MATERIAL AND METHODS

We used a questionnaire enclosing respondents' sociodemographic information, five psychological and behavioral tests including Dysfunctional Beliefs and Attitudes about Sleep (DBAS-16), Athens Insomnia Scale (AIS), Epworth Sleepiness Scale (ESS), Hamilton Anxiety Rating Scale (HARS) and Beck Depression Inventory (BDI) test.

RESULTS

Our results highlighted widespread false beliefs about sleep and the prevalence of sleep disorders, anxiety, and depression-related symptoms within the Moroccan population. Nearly 82.3% of respondents revealed false beliefs about sleep. Furthermore, we confirmed a strong positive correlation between knowledge and attitudes about sleep and the prevalence of sleep disorders, anxiety, and depression-related symptoms. However, we found no significant difference in the prevalence of sleep and psychological disorders, between healthcare workers and other professions workers.

CONCLUSION

Our study revealed a high prevalence of sleep disorders, anxiety, and depressive symptoms in the Moroccan population during the COVID-19 lockdown period. Moreover, false beliefs on sleep understanding were prevalent and were presenting a risk factor leading to sleep disorders, anxiety, and depressive symptoms.

Comparative Effectiveness of Cheonwangbosimdan (Tian Wang Bu Xin Dan) Versus Cognitive-Behavioral Therapy for Insomnia in Cancer Patients: A Randomized, Controlled, Open-Label, Parallel-Group, Pilot Trial

Cancer patients have a 2 times higher prevalence of insomnia than healthy populations and cancer-related insomnia has received minimal attention while insomnia can aggravate the rehabilitation of cancer patients. Cheonwangbosimdan is a Korean herbal medicine generally used to relieve sleep deprivation, however, few studies presented the effects of Cheonwangbosimdan on cancer-related insomnia. The purpose of study is to examine the feasibility of Cheonwangbosimdan treatments for cancer patients. Twenty-two participants were allocated into a Cheonwangbosimdan or cognitive-behavioral therapy for insomnia (CBT-I) control group by equal number. The intervention group took Cheonwangbosimdan liquid once in a day and attend visits once a week for 4 weeks. The CBT-I group underwent individualized behavioral therapy 4 times in 4 weeks. The primary outcome is changes in the Insomnia Severity Index (ISI) from baseline to the end of the trial. Responses to the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Zung Self-Rating Anxiety Scale (SAS), Brief Fatigue Inventory (BFI), Euroqol-5 Dimensions-5 Levels (EQ-5D-5L), and Eastern Cooperative Oncology Group Performance Status (ECOG-PS) were secondary outcomes used to evaluate the quality of sleep. Outcomes were measured at a follow-up visit (visit 5) in the fifth week of the trial. There is no difference between 2 groups, but both groups showed tendency to alleviate cancer insomnia symptoms. SAS-K showed significant difference between the 2 groups (P < .001), as treatment group score was highly lowered than control group score. The study can contribute to more attentive care for insomnia in cancer patients.

Effects of exercise therapy in cancer patients undergoing radiotherapy treatment: a narrative review

Despite its beneficial effects, radiotherapy still results in a range of side effects that negatively impact quality of life of patients. Exercise has been shown to counteract the side effects induced by cancer treatment. This narrative review aims to provide an up-to-date review of the effects of an exercise intervention in cancer patients during radiotherapy. A literature search was performed on PubMed to identify original articles that evaluated the effects of an exercise programme to alleviate treatment-related side effects in cancer patients undergoing radiotherapy with or without other cancer treatments. Benefits related to exercise training have been shown in breast, prostate, rectal, lung, head and neck cancer patients undergoing radiotherapy. Therefore, exercise should be considered as a concurrent treatment alongside radiotherapy to alleviate treatment-related side effects and facilitate effective recovery. Due to the onset and progress of treatment-related side effects throughout radiotherapy, a regular clinical evaluation seems strongly advisable in order to continuously adapt the exercise programme depending on symptoms and side effects. An exercise professional is needed to personalize exercise training based on the medical condition and tailor it throughout the intervention according to progress and the patient’s medical status. Future studies are needed to confirm the potential benefits of exercises observed on treatment-related side effects. Furthermore, because of the narrative design of this study, a systematic review is required to evaluate the strength of the evidence reported.

Light-enhanced cognitive behavioural therapy for sleep and fatigue: study protocol for a randomised controlled trial during chemotherapy for breast cancer

BACKGROUND

Women with breast cancer experience a significantly higher prevalence of sleep disturbance and insomnia than the general population. The experience of persistent sleep disturbance places these women at a higher risk of psychological and physical morbidity and a reduced quality of life. Treatment for sleep in this population is not part of routine care and is often managed inadequately. This randomised controlled trial will examine the combined effects of cognitive behavioural therapy (CBT) and bright light therapy (BLT) on the symptoms of insomnia, fatigue and mental health.

METHOD/DESIGN

Women diagnosed with breast cancer who receive intravenous chemotherapy treatment at a quaternary referral metropolitan cancer centre in Melbourne, Australia, will be recruited. Recruitment will occur after diagnosis and prior to completion of chemotherapy. Eligible women will be randomised to the combined CBT and BLT intervention (CBT+) or relaxation audio-enhanced treatment as usual (TAU+). The CBT+ group will receive one face-to-face session on sleep strategies, one subsequent telephone call, and seven email packages containing CBT-based information and strategies. CBT+ participants will also wear Luminette® light glasses for 20 min each morning for the 6-week duration of the intervention. Women in TAU+ will receive two relaxation audio tracks via email. Outcomes will be measured at multiple points throughout the 6 weeks. Primary outcomes will be symptoms of insomnia and sleep efficiency, measured using the Insomnia Severity Index and a self-reported sleep diary. Secondary outcomes include objective measures of sleep assessed using the ActiGraph wGT3X-BT, and sleep-related complaints, fatigue and mental health, all assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS). Data will also be collected on potential treatment moderators and mechanisms and adherence to treatment. There will be 3-month follow-up measurements of insomnia symptoms, fatigue, sleep-related impairment, sleep disturbance, depression and anxiety.

DISCUSSION

This is the first randomised controlled trial to combine CBT and BLT for the treatment of sleep disturbance in women with breast cancer. This novel design addresses the multiple causal factors for sleep complaints in this population. Results from this trial will advance knowledge in this field and may have important clinical implications for how best to treat sleep disturbance and insomnia in this population. If effective, the largely email-based format of the intervention would allow for relatively easy translation.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001255279. Retrospectively registered on 25 July 2018.

Quality of Sleep in Patients with Cancer: A Cross-sectional Observational Study

Background:

Insomnia and poor sleep quality are common problems in patients with cancer. It interferes with the coping ability, symptoms, and treatment outcomes. The Pittsburgh Sleep Quality Index (PSQI) is a reliable, valid instrument to assess the quality of sleep in patients with cancer.

Patients and Methods:

The study was conducted at the department of medical oncology of a tertiary cancer care center. Consecutive eligible participants were recruited and evaluated for sleep quality using PSQI questionnaire. The questionnaire was administered only once with the questions evaluating to the quality of sleep over the last 1 month. A PSQI total score of ≤5 was suggestive of good quality of sleep and a score of >5 was indicative of poor quality of sleep.

Results:

Ninety-two consecutive consenting cancer patients admitted for chemotherapy participated in the study. Thirty-one (33.7%) patients had early cancer and 35 (38%) patients had Stage IV metastatic disease. Thirty-six (39.1%) patients reported sleep of <6 h and 30 (32.6%) patients had impaired functioning during day due to sleepiness. Fifty-three (57.6%) patients had poor total PSQI score, of which 39 (73.5%) were female and 14 (26.5%) were male. The study showed no correlation of the PSQI scores with the stage of the disease, and the prior treatment received.

Conclusions:

The study showed that Indian cancer patients have short sleep duration and poor quality of sleep. A higher prevalence of sleep disturbances was seen among female cancer patients. PSQI questionnaire can be a cost-effective way of screening cancer patients for poor quality of sleep.