Trajectories of sleep disturbance in cancer survivors during the first 2 years post-treatment

Tai Chi compared with cognitive behavioral therapy and the reversal of systemic, cellular and genomic markers of inflammation in breast cancer survivors with insomnia: A randomized clinical trial

BACKGROUND

Insomnia contributes to inflammation in breast cancer survivors. This study evaluates whether insomnia treatment reverses inflammation in breast cancer survivors with insomnia.

METHODS

Participants (n = 90) were randomized to 3 months of Tai Chi (n = 45) or cognitive behavioral therapy for insomnia (CBT-I)(n = 45), and followed for one year post-intervention to 15 month endpoint. Our previous report found that Tai Chi as compared to CBT-I resulted in similar rates of insomnia response and remission over 15 months. Here, we analyze changes in plasma C-reactive protein and pro- and anti-inflammatory cytokines, Toll-like receptor (TLR)-4 stimulated monocyte production of interleukin (IL)-6 and tumor necrosis factor-α (TNF), and cellular pro-inflammatory and anti-viral gene expression (Conserved Transcriptional Response to Adversity RNA profile; CTRA) over 15 months.

RESULTS

Insomnia treatment resulted in decreases in the TLR-4 stimulated monocyte production of IL-6, TNF, and their co-expression, as well as decreases in the CTRA profile, decreases inflammatory gene transcripts, and increases in anti-viral gene transcripts over 15 months (all P's < 0.01). In addition, as compared to CBT-I, Tai Chi resulted in greater decreases in plasma IL-6 (P < 0.05), and greater decreases in TLR-4 activated monocyte production of IL-6 and co-expression of IL-6 and TNF at 15 month endpoint. CBT-I resulted in greater increases in anti-viral gene transcripts.

CONCLUSIONS

Administration of either CBT-I or Tai Chi effectively treats insomnia, and shows additional benefits of reducing cellular and genomic markers of inflammation, and increasing anti-viral genomic markers in breast cancer survivors with insomnia. Tai Chi, as compared to CBT-I, yields greater and more durable decreases in systemic- and cellular inflammation. Targeting insomnia might mitigate the risk of inflammation-related co-morbidities in breast cancer survivors.

Prevalence and determinants of sleep problems in cancer survivors compared to a normative population: a PROFILES registry study

PURPOSE

To (1) identify the prevalence of sleep problems in cancer survivors across cancer types and survivorship durations compared to a normative population and (2) determine demographic, clinical, lifestyle, and psychosocial determinants.

METHOD

Cancer survivors diagnosed between 2008 and 2015 (N = 6736) and an age- and sex-matched normative cohort (n = 415) completed the single sleep item of the EORTC QLQ-C30: Have you had trouble sleeping? Participants who responded with "quite a bit"/ "very much" were categorized as poor sleepers. A hierarchical multinomial logistic regression was used to identify determinants of sleep problems.

RESULT

The prevalence of sleep problems was higher in cancer survivors (17%) compared to the normative population (11%) (p < 0.001), varied across cancer types (10-26%) and did not vary based on survivorship duration. The full model showed that survivors who were female (adjusted odds ratio (AOR) 2.26), overweight (AOR 1.50), had one (AOR 1.25) and ≥ 2 comorbidities (AOR 2.15), were former (AOR 1.30) and current (AOR 1.53) smokers and former alcohol drinkers (AOR 1.73), had a higher level of fatigue (AOR 1.05), anxiety (AOR 1.14), depression (AOR 1.11), and cognitive illness perceptions (AOR 1.02), had a higher odds for sleep problems. Higher education compared to lower education (AOR 0.67), having a partner (AOR 0.69), and obesity compared to normal BMI (AOR 0.86) were protective to sleep problems as well as high physical activity before adjusting for psychological factors (AOR 0.91).

CONCLUSION

Modifiable determinants of sleep problems include physical activity, fatigue, anxiety, depression, and illness perception.

IMPLICATIONS FOR CANCER SURVIVORS

Sleep problems after cancer deserve clinical attention. They may be improved by addressing modifiable lifestyle factors: increasing physical activity, stop smoking, and reducing alcohol consumption. As fatigue, depression, and illness perception seem related to sleep problems, lifestyle improvements may also improve these outcomes.

Follow-up assessment of sleep-related symptoms in patients after treatment for cancer: responses to continuous positive airway pressure treatment for co-morbid obstructive sleep apnoea

PURPOSE

To assess changes in sleep-related symptoms in patients with breast cancer, endometrial cancer and melanoma previously examined for sleep-related symptoms and the presence of PSG (polysomnography)-determined OSA, ≥ 3 years post-treatment; and to evaluate how CPAP treatment affects sleep-related symptoms in patients previously diagnosed with OSA.

METHODS

Patients initially recruited from breast cancer, endometrial cancer, and melanoma follow-up clinics at Westmead Hospital (Sydney, Australia) participated in this questionnaire-based study. Demographic and change in cancer status data were collected at follow-up. Patients completed the Pittsburgh Sleep Quality Index [poor sleep quality, PSQITOTAL ≥ 5au], Insomnia Severity Index, Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire; with ΔPSQITOTAL ≥ 3au indicating a clinically meaningful change in sleep quality over follow-up. PSG-determined OSA was confirmed using the apnoea-hypopnoea index. CPAP compliance was determined via self-report (CPAP compliant, CPAP; not compliant, non-CPAP). Logistic regression models determined if changes in cancer status, AHI, cancer subgroup or CPAP treatment was predictive of ΔPSQITOTAL ≥ 3 au and p < 0.05 indicated statistical significance.

RESULTS

The 60 patients recruited had breast cancer (n = 22), endometrial cancer (n = 15), and melanoma (n = 23). Cancer subgroups were similarly aged, and all had median follow-up PSQITOTAL scores ≥ 5au; breast cancer patients scoring the highest (p < 0.05). The CPAP group had significantly reduced PSQITOTAL scores (p = 0.02) at follow-up, unlike the non-CPAP group. Cancer subgroups had similar median ISITOTAL, ESSTOTAL and FOSQ-10TOTAL scores at follow-up, regardless of CPAP treatment. There were no significant predictors of ΔPSQITOTAL ≥ 3 au at follow-up.

CONCLUSION

Sleep-related symptoms persist in patients with cancer ≥ 3 years after treatment, although these symptoms improve with CPAP. Future studies should evaluate how CPAP affects survival outcomes in cancer patients with comorbid OSA.