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Lai F, Luo Z, Zhang J, Xia W, Tian L. Bright light therapy has a positive effect on sleep quality in patients with cancer: A meta-analysis. Sleep Med Rev 2024; 75:101925. [PMID: 38537515 DOI: 10.1016/j.smrv.2024.101925] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/29/2024] [Accepted: 03/17/2024] [Indexed: 06/04/2024]
Abstract
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.
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Affiliation(s)
- Fengxia Lai
- The First Affiliated Hospital of Soochow University, Suzhou, 215006, China; School of Nursing, Medical College of Soochow University, Suzhou, 215006, China
| | - Zhen Luo
- School of Nursing, Medical College of Soochow University, Suzhou, 215006, China
| | - Jiyin Zhang
- School of Nursing, Medical College of Soochow University, Suzhou, 215006, China
| | - Wangjie Xia
- School of Nursing, Medical College of Soochow University, Suzhou, 215006, China
| | - Li Tian
- The First Affiliated Hospital of Soochow University, Suzhou, 215006, China; School of Nursing, Medical College of Soochow University, Suzhou, 215006, China.
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Nissen ER, Neumann H, Knutzen SM, Henriksen EN, Amidi A, Johansen C, von Heymann A, Christiansen P, Zachariae R. Interventions for insomnia in cancer patients and survivors-a comprehensive systematic review and meta-analysis. JNCI Cancer Spectr 2024; 8:pkae041. [PMID: 38781520 PMCID: PMC11188797 DOI: 10.1093/jncics/pkae041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/19/2024] [Accepted: 05/12/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Considering the persistent nature and higher prevalence of insomnia in cancer patients and survivors compared with the general population, there is a need for effective management strategies. This systematic review and meta-analysis aimed to comprehensively evaluate the available evidence for the efficacy of pharmacological and nonpharmacological interventions for insomnia in adult cancer patients and survivors. METHODS Following the PRISMA guidelines, we analyzed data from 61 randomized controlled trials involving 6528 participants. Interventions included pharmacological, physical, and psychological treatments, with a focus on insomnia severity and secondary sleep and non-sleep outcomes. Frequentist and Bayesian analytical strategies were employed for data synthesis and interpretation. RESULTS Cognitive-Behavioral Therapy for Insomnia (CBT-I) emerged as the most efficacious intervention for reducing insomnia severity in cancer survivors and further demonstrated significant improvements in fatigue, depressive symptoms, and anxiety. CBT-I showed a large postintervention effect (g = 0.86; 95% confidence interval [CI] = 0.57 to 1.15) and a medium effect at follow-up (g = 0.55; 95% CI = 0.18 to 0.92). Other interventions such as bright white light therapy, sleep medication, melatonin, exercise, mind-body therapies, and mindfulness-based therapies showed benefits, but the evidence for their efficacy was less convincing compared with CBT-I. Brief Behavioral Therapy for Insomnia showed promise as a less burdensome alternative for patients in active cancer treatment. CONCLUSIONS CBT-I is supported as a first-line treatment for insomnia in cancer survivors, with significant benefits observed across sleep and non-sleep outcomes. The findings also highlight the potential of less intensive alternatives. The research contributes valuable insights for clinical practice and underscores the need for further exploration into the complexities of sleep disturbances in cancer patients and survivors.
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Affiliation(s)
- Eva Rames Nissen
- Unit for Psychooncology and Health Psychology, Department of Oncology Aarhus University Hospital, and Department of Psychology, Aarhus University, Aarhus, Denmark
| | - Henrike Neumann
- Unit for Psychooncology and Health Psychology, Department of Oncology Aarhus University Hospital, and Department of Psychology, Aarhus University, Aarhus, Denmark
| | - Sofie Møgelberg Knutzen
- Unit for Psychooncology and Health Psychology, Department of Oncology Aarhus University Hospital, and Department of Psychology, Aarhus University, Aarhus, Denmark
| | - Emilie Nørholm Henriksen
- Centre for Involvement of Relatives, Mental Health Services, Region of Southern Denmark, Odense, Denmark
| | - Ali Amidi
- Unit for Psychooncology and Health Psychology, Department of Oncology Aarhus University Hospital, and Department of Psychology, Aarhus University, Aarhus, Denmark
| | - Christoffer Johansen
- Cancer Survivorship and Treatment Late Effects (CASTLE) – a Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Annika von Heymann
- Cancer Survivorship and Treatment Late Effects (CASTLE) – a Danish Cancer Society National Research Center, Department of Oncology, Copenhagen University Hospital Rigshospitalet, Denmark
| | - Peer Christiansen
- Department of Plastic and Breast Surgery, Aarhus University Hospital, Aarhus, Denmark
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
| | - Robert Zachariae
- Unit for Psychooncology and Health Psychology, Department of Oncology Aarhus University Hospital, and Department of Psychology, Aarhus University, Aarhus, Denmark
- Danish Breast Cancer Group Center and Clinic for Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
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3
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Hung CM, Zeng BY, Zeng BS, Sun CK, Cheng YS, Su KP, Wu YC, Chen TY, Lin PY, Liang CS, Hsu CW, Chu CS, Chen YW, Yeh PY, Wu MK, Tseng PT, Matsuoka YJ. Cancer related fatigue-light therapy: updated meta-analysis of randomised controlled trials. BMJ Support Palliat Care 2023; 13:e437-e445. [PMID: 34266911 DOI: 10.1136/bmjspcare-2021-003135] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/28/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Moderate-to-severe cancer related fatigue occurs in 45% of patients with cancer and interferes with many aspects of quality of life. Although physical exercise has level 1 evidence for improvement of cancer related fatigue, it has a relatively high behavioural demand compared with other non-pharmacological interventions. The aim of this updated meta-analysis was to address the efficacy of light therapy in improving cancer related fatigue in patients with cancer. METHODS We included randomised controlled trials investigating the efficacy of bright white light (BWL) therapy in ameliorating cancer related fatigue in patients with cancer. This meta-analysis was conducted using a random-effects model. The target outcomes were changes in cancer related fatigue associated with BWL or dim red light (DRL). RESULTS There were 9 articles with 231 participants included. The main results revealed that daily morning BWL for 30 min was associated with significantly better improvement in fatigue severity compared with DRL (k=5, Hedges' g=-0.414, 95% CI -0.740 to -0.087, p=0.013). The subgroup without psychiatric comorbidities (k=4, Hedges' g=-0.479, 95% CI -0.801 to -0.156, p=0.004) was associated with significantly better improvement in fatigue severity with BWL than with DRL. In contrary, BWL was not associated with significantly different changes in depression severity or quality of life compared with DRL. Finally, BWL was associated with similar acceptability (ie, dropout rate) and safety profile (ie, any discomfort) as those of DRL. CONCLUSIONS This meta-analysis provides an updated evidence on the rationale for application of BWL in ameliorating cancer related fatigue in patients with different types of cancer. TRIAL REGISTRATION NUMBER INPLASY202140090.
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Affiliation(s)
- Chao-Ming Hung
- Division of General Surgery, Department of Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Bing-Yan Zeng
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Bing-Syuan Zeng
- Department of Internal Medicine, E-Da Hospital, Kaohsiung, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Yu-Shian Cheng
- Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Kaohsiung, Taiwan
| | - Kuan-Pin Su
- Mind-Body Interface Laboratory (MBI-Lab), China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Sung Liang
- School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Che-Sheng Chu
- Department of Psychiatry, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Center for Geriatric and Gerontology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
| | - Pin-Yang Yeh
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Ming-Kung Wu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Ping-Tao Tseng
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
| | - Yutaka J Matsuoka
- Research and Development Division, Health Policy Bureau, Ministry of Health, Labour and Welfare, Tokyo, Japan
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Grassi L, Zachariae R, Caruso R, Palagini L, Campos-Ródenas R, Riba MB, Lloyd-Williams M, Kissane D, Rodin G, McFarland D, Ripamonti CI, Santini D. Insomnia in adult patients with cancer: ESMO Clinical Practice Guideline. ESMO Open 2023; 8:102047. [PMID: 38158225 PMCID: PMC10774975 DOI: 10.1016/j.esmoop.2023.102047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 01/03/2024] Open
Abstract
•Insomnia is common in patients with cancer, with a higher prevalence than observed in the general population. •Insomnia is often under-recognised and inadequately treated in patients with cancer. •Brief validated screening tools are available for the evaluation of insomnia in clinical practice. •First-line therapy should be based on international guidelines recommending cognitive behavioural therapy for insomnia.
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Affiliation(s)
- L Grassi
- Institute of Psychiatry, Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - R Zachariae
- Unit for Psychooncology and Health Psychology (EPoS), Department of Oncology, Aarhus University Hospital, Aarhus; Danish Center for Breast Cancer Late Effects (DCCL), Aarhus University Hospital, Aarhus, Denmark
| | - R Caruso
- Institute of Psychiatry, Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy
| | - L Palagini
- Sleep Clinic, Department of Clinical and Experimental Medicine, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
| | - R Campos-Ródenas
- Department of Psychiatry, Hospital Clínico Universitario Lozano Blesa, University of Zaragoza, Zaragoza, Spain
| | - M B Riba
- Department of Psychiatry, University of Michigan, Ann Arbor; University of Michigan Rogel Cancer Center, University of Michigan, Ann Arbor, USA
| | - M Lloyd-Williams
- Academic Palliative and Supportive Care Studies Group (APSCSG), Primary Care and Mental Health, University of Liverpool, Liverpool; Department of Supportive and Palliative Care, Liverpool John Moores University, Liverpool, UK
| | - D Kissane
- Department of Psychiatry, Monash University and Monash Medical Centre, Monash Health, Clayton, Australia
| | - G Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada
| | - D McFarland
- Department of Psychiatry, University of Rochester, Rochester; Wilmont Cancer Institute, University of Rochester Medical Center, Rochester, USA
| | - C I Ripamonti
- School of Speciality in Palliative Medicine, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia
| | - D Santini
- Medical Oncology A, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
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5
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Lin LY, Tam KW, Huang TW. Effect of bright light therapy on cancer-related fatigue and related symptoms: A systematic review and meta-analysis of randomized controlled trials. J Psychosom Res 2023; 174:111501. [PMID: 37797569 DOI: 10.1016/j.jpsychores.2023.111501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Revised: 09/24/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE Cancer-related fatigue (CRF) is a common side effect in cancer patients, possibly due to disrupted circadian rhythms. While bright light therapy (BLT) is known to modulate circadian rhythms, its role in mitigating CRF remains unclear. This study examined the impact of BLT on CRF and other related symptoms. METHODS PubMed, Embase, Cochrane Library, and SCOPUS databases were searched. The trials were selected according to the PRISMA guidelines. The severity and quality of CRF and related symptoms were investigated in post-BLT intervention. RESULTS Twelve trials involving 691 were included. BLT significantly reduced CRF (SMD = -0.92, 95% CI: -1.45 to -0.40, p < 0.00001, I2 = 90%) and insomnia (SMD = -2.80, 95% CI: -4.61 to -0.98, I2 = 0%). Subgroup analyzes were performed based on various factors including light illuminance and intervention duration. BLT was found to be effective in both preventing and treating CRF, though it did not significantly enhance sleep quality, depression, and quality of life (QoL). CONCLUSION BLT is a promising intervention for managing CRF in cancer patients. Its efficacy in improving sleep quality, and insomnia, reducing depression, and enhancing QoL requires further exploration. A 4-week BLT intervention with ≥10,000 lx is recommended for preventing and treating CRF, with longer or less intense interventions also showing effectiveness. Otherwise, BLT exhibited minimal adverse effects.
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Affiliation(s)
- Lee-Yuan Lin
- School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Ka-Wai Tam
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.
| | - Tsai-Wei Huang
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan; School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan; Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
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6
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Carlson LE, Ismaila N, Addington EL, Asher GN, Atreya C, Balneaves LG, Bradt J, Fuller-Shavel N, Goodman J, Hoffman CJ, Huston A, Mehta A, Paller CJ, Richardson K, Seely D, Siwik CJ, Temel JS, Rowland JH. Integrative Oncology Care of Symptoms of Anxiety and Depression in Adults With Cancer: Society for Integrative Oncology-ASCO Guideline. J Clin Oncol 2023; 41:4562-4591. [PMID: 37582238 DOI: 10.1200/jco.23.00857] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/13/2023] [Indexed: 08/17/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations to health care providers on integrative approaches to managing anxiety and depression symptoms in adults living with cancer. METHODS The Society for Integrative Oncology and ASCO convened an expert panel of integrative oncology, medical oncology, radiation oncology, surgical oncology, palliative oncology, social sciences, mind-body medicine, nursing, methodology, and patient advocacy representatives. The literature search included systematic reviews, meta-analyses, and randomized controlled trials published from 1990 through 2023. Outcomes of interest included anxiety or depression symptoms as measured by validated psychometric tools, and adverse events. Expert panel members used this evidence and informal consensus with the Guidelines into Decision Support methodology to develop evidence-based guideline recommendations. RESULTS The literature search identified 110 relevant studies (30 systematic reviews and 80 randomized controlled trials) to inform the evidence base for this guideline. RECOMMENDATIONS Recommendations were made for mindfulness-based interventions (MBIs), yoga, relaxation, music therapy, reflexology, and aromatherapy (using inhalation) for treating symptoms of anxiety during active treatment; and MBIs, yoga, acupuncture, tai chi and/or qigong, and reflexology for treating anxiety symptoms after cancer treatment. For depression symptoms, MBIs, yoga, music therapy, relaxation, and reflexology were recommended during treatment, and MBIs, yoga, and tai chi and/or qigong were recommended post-treatment. DISCUSSION Issues of patient-health care provider communication, health disparities, comorbid medical conditions, cost implications, guideline implementation, provider training and credentialing, and quality assurance of natural health products are discussed. While several approaches such as MBIs and yoga appear effective, limitations of the evidence base including assessment of risk of bias, nonstandardization of therapies, lack of diversity in study samples, and lack of active control conditions as well as future research directions are discussed.Additional information is available at www.asco.org/survivorship-guidelines.
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Affiliation(s)
- Linda E Carlson
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | | | | | - Gary N Asher
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Chloe Atreya
- University of California San Francisco, San Francisco, CA
| | | | - Joke Bradt
- Department of Creative Arts Therapies, Drexel University, Philadelphia, PA
| | | | | | | | - Alissa Huston
- University of Rochester Medical Center, Rochester, NY
| | | | - Channing J Paller
- Sidney Kimmel Comprehensive Cancer Center, John Hopkins University, Baltimore, MD
| | | | - Dugald Seely
- University of Ottawa, Ottawa, ON, Canada
- Canadian College of Naturopathic Medicine, Toronto, ON, Canada
| | - Chelsea J Siwik
- Osher Center for Integrative Health, University of California, San Francisco, San Francisco, CA
| | - Jennifer S Temel
- Massachusetts General Hospital and Harvard Medical School, Boston, MA
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7
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Yao L, Zhang Z, Lam LT. The effect of light therapy on sleep quality in cancer patients: a systematic review and meta-analysis of randomized controlled trials. Front Psychiatry 2023; 14:1211561. [PMID: 37492065 PMCID: PMC10363736 DOI: 10.3389/fpsyt.2023.1211561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/22/2023] [Indexed: 07/27/2023] Open
Abstract
Background Sleep problem is one of the major issues of cancer patients and may have detrimental effects on the ongoing treatment and recovery of patients. However, the evidence for the effect of light therapy on sleep problems in this population remained scarce. This study aimed to examine the effect of light therapy on self-reported and physiological measures of sleep quality of cancer patients. It also aimed to quantify the magnitude of the effect using a meta-analytical approach. Methods Six databases were searched for randomized control trials (RCTs). The primary outcome was the sleep quality using the Pittsburgh sleep quality index (PSQI) measurement of self-reported scores, and the secondary outcomes included total sleep time and sleep efficiency measured by actigraphy. Meta-analyses were performed with the random effects model using the RevMan software. The standardized mean difference (SMD) of the PSQI scores and other measures with their 95% confidence intervals (CIs) were used for assessing the treatment effect (CRD42023370947). Results Nine RCTs were identified and included in the study. Light therapy significantly improved the self-reported sleep quality with a reduction of the pooled PSQI score (SMD = -0.72; 95% CI: -1.24 to -0.21; p = 0.006). Regarding total sleep time (p = 0.72) and sleep efficiency (p = 0.47), no significant effects of light therapy were found. Conclusion Light therapy could improve self-reported sleep quality in cancer patients. However, due to the heterogeneity and small sample size of the included trials, the results should be interpreted cautiously. Trials with better designs and larger sample sizes are suggested to be conducted for a more definitive conclusion.Systematic review registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=370947.
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Affiliation(s)
- Liqing Yao
- Faculty of Medicine, Macau University of Science and Technology, Taipa, Macao SAR, China
| | - Zhiyi Zhang
- Faculty of Health Sciences, University of Macau, Taipa, Macao SAR, China
| | - Lawrence T. Lam
- Faculty of Medicine, Macau University of Science and Technology, Taipa, Macao SAR, China
- Faculty of Health, The University of Technology Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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8
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Yennurajalingam S, Konopleva M, Carmack CL, Dinardo CD, Gaffney M, Michener HK, Lu Z, Stanton P, Ning J, Qiao W, Bruera E. Treatment of Cancer-related-Fatigue in Acute Hematological Malignancies: Results of a Feasibility Study of using Cognitive Behavioral Therapy. J Pain Symptom Manage 2023; 65:e189-e197. [PMID: 36384181 DOI: 10.1016/j.jpainsymman.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 10/26/2022] [Accepted: 11/08/2022] [Indexed: 11/14/2022]
Abstract
BACKGROUND Despite cancer related fatigue (CRF) being the most common, and debilitating symptom in patients with recently diagnosed acute hematological malignancies (HM), there are limited effective treatments for CRF in HM. The aim of this study was to determine the feasibility of cognitive behavioral therapy (CBT) for CRF in HM. METHODS In this preliminary longitudinal prospective study, HM patients diagnosed a median of one month previously with moderate to severe fatigue were enrolled. Patients received CBT in seven weekly sessions for eight weeks. Change in Functional Assessment of Cancer Illness Therapy (FACIT) - Fatigue (primary), FACT-G, Pittsburg Sleep Quality Index (PSQI), Hospital Anxiety Depression Scale (HADS), M.D. Anderson Symptom Inventory - Acute Myeloid Leukemia (MDASI-AML/MDS), and Herth Hope Index (HHI) were analyzed. RESULTS Twenty-seven of 36 (75 %) patients were evaluable. Adherence and satisfaction rates to the CBT intervention were 78.6% (95% CI 67.2%, 89.9%), and 92% (95% CI 76.7%, 98.3%) respectively. The median age 66, 64% female, the most common HM was AML (60%), median FACIT-F was 27. The mean (SD) improvement at end eight weeks for FACIT-F was 5.5(13.6), Cohen δ 0.4, P=0.046; and for PSQI total was 2.9 (3), Cohen δ -1, P=0.006. We also found significant improvement in HADS anxiety -2.7(4.5), P=0.049, MDASI Sleep -1.8(3.0), P=0.022, MDASI mean module symptom severity -0.7(1.6), P=0.006. However, no significant improvements were found in FACT-G, HHI, and HADS-depression scores. CONCLUSIONS The use of CBT was feasible with improvement of CRF, sleep quality, and anxiety scores in HM. Randomized controlled trials are justified.
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Affiliation(s)
- Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center.
| | - Marina Konopleva
- Departments of Leukemia and Stem Cell Transplantation, (M.K.,C.D.), The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Cindy L Carmack
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
| | - Courtney D Dinardo
- Departments of Leukemia and Stem Cell Transplantation, (M.K.,C.D.), The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Melissa Gaffney
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
| | - Hayley Kristen Michener
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
| | - Zhanni Lu
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
| | - Penny Stanton
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
| | - Jing Ning
- Department of Biostatistics, (J.N., W.Q.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Wei Qiao
- Department of Biostatistics, (J.N., W.Q.), The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, (S.Y.,C.C.,H.M.,Z.L.,P.S.,E.B.), The University of Texas MD Anderson Cancer Center, Houston, USA Center
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9
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Mosavat SH, Mirzaei HR, Mofid B, Gharehgozlou R, Parvizi MM, Bradley R, Pasalar M, Heydarirad G. Efficacy of lettuce seed syrup on insomnia in patients with breast cancer: a pilot double blind randomized placebo controlled clinical trial. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2022; 19:999-1005. [PMID: 34455726 DOI: 10.1515/jcim-2021-0181] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/19/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES Insomnia and sleep disorders are common and can be severe amongst patients with cancer, especially during chemotherapy. The aim of this study was to evaluate the efficacy of lettuce seed syrup in breast cancer patients who suffer from insomnia or disordered sleep. METHODS This pilot study was a double-blinded randomized controlled clinical trial conducted in Shoha-e-Tajrish Hospital (Tehran, Iran) from September 2018 to June 2019. 50 adult patients with breast cancer with insomnia or sleep disorders were enrolled. Participants were randomly allocated to lettuce seed syrup (5 mL twice daily), or placebo syrup at the same dose for four weeks. The Pittsburgh Sleep Quality Index (PSQI) was used to evaluate sleep quality before and after the intervention. RESULTS Compared to placebo, the mean of the total PSQI score decreased significantly in participants who received lettuce seed syrup (p=0.014). In addition, there were statistically significant reductions in the mean scores of subject quality sleep (p=0.002), sleep duration (p=0.038), habitual sleep efficacy (p=0.029) and sleep disturbance (p=0.032) in patients who received lettuce seed syrup. CONCLUSIONS Lettuce seed syrup may improve self-reported sleep quality in participants with breast cancer. Larger trials are indicated in diverse samples of participants with caner to learn if these finds are generalizable.
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Affiliation(s)
- Seyed Hamdollah Mosavat
- Pharmaceutical Sciences Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Research Center for Psychiatry and Behavior Science, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hamid Reza Mirzaei
- Cancer Research Center, Department of Radiation Oncology, Shohadae Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bahram Mofid
- Department of Clinical Oncology, Shohada-e-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Gharehgozlou
- Cancer Research Center, Department of Radiation Oncology, Shohadae Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdi Parvizi
- Molecular Dermatology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ryan Bradley
- Helfgott Research Institute, National University of Natural Medicine, Portland, USA
| | - Mehdi Pasalar
- Research Center for Traditional Medicine and History of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ghazaleh Heydarirad
- Traditional Medicine and Materia Medica Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- School of Traditional Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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10
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Fan R, Bu X, Yang S, Tan Y, Wang T, Chen H, Li X. Effect of melatonin on quality of life and symptoms in patients with cancer: a systematic review and meta-analysis of randomised controlled trials. BMJ Open 2022; 12:e060912. [PMID: 36104141 PMCID: PMC9476160 DOI: 10.1136/bmjopen-2022-060912] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study systematically reviewed the effect of melatonin (MLT) on quality of life (QoL) and symptoms among patients with cancer. DESIGN Systematic review and meta-analysis. DATA SOURCES Cochrane Library, PubMed, Embase, Web of Science, Medline, CINAHL, Scopus, ClinicalTrials.gov, China Biology Medicine (CBM), ProQuest and Open Grey were searched from inception to November 2021. ELIGIBILITY CRITERIA We included randomised controlled trials (RCTs) assessing the effects of MLT on QoL, sleep quality, fatigue, depression, pain, stomatitis rate and stomatitis severity in adult patients with cancer, without language restrictions. Studies that reported the effects of MLT along with other interventions and had incomplete or absent outcome data were excluded. DATA EXTRACTION AND SYNTHESIS Two independent reviewers extracted data, and another two reviewers assessed the risk of bias. The risk of bias for each eligible study was assessed using the Cochrane assessment tool. The mean difference or standard mean difference (SMD) with 95% CIs was used in the computation of continuous variables to synthesise data. The relative risk was used for dichotomous outcomes. Heterogeneity was assessed and quantified (I2 statistic). RESULTS A total of 19 qualified studies that included 2101 patients with cancer (MLT: 1078, control: 1023) were included in the meta-analysis. The results indicated that MLT had no significant effect on QoL (SMD=-0.01, 95% CI (-0.14 to 0.11), p=0.83), sleep quality (SMD=-0.18, 95% CI (-0.62 to 0.26), p=0.42), fatigue (SMD=-0.34, 95% CI (-0.73 to 0.06), p=0.10), pain (SMD=-0.34, 95% CI (-0.7 to 0.02), p=0.06) or stomatitis severity (RR=0.78, 95% CI (0.47 to 1.30), p=0.35). MLT reduced stomatitis rate among patients with cancer (RR=0.47, 95% CI (0.26 to 0.88), p=0.02), except those with head and neck cancer (RR=1.09, 95% CI (0.92 to 1.29), p=0.35). MLT eased depression in patients who received administration for more than 14 days (SMD=-0.14, 95% CI (-0.27 to -0.01), p=0.03) and those who underwent surgery (SMD=-0.17, 95% CI (-0.32 to -0.03), p=0.02). CONCLUSION The findings showed that MLT did not improve the QoL, sleep quality, fatigue, pain or stomatitis severity among patients with cancer. It had a limited effect on decreasing the stomatitis rate and easing depression. Different treatments, durations and cancer types were the main sources of heterogeneity. Further large-scale RCTs are urgently needed. In addition, the effects of different combinations of MLT dosage and duration, administration types and joint measures are worthy of further study. PROSPERO REGISTRATION NUMBER CRD42021292855.
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Affiliation(s)
- Rongrong Fan
- Department of Nursing Teaching and Research, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China/Xiangya Center for Evidence-Based Practice & Healthcare Innovation: A Joanna Briggs Institute Affiliated Group, Changsha, China
| | - Xiaofan Bu
- Xiangya Nursing school of Central South University, Changsha, China/Xiangya Center for Evidence-Based Practice & Healthcare Innovation: A Joanna Briggs Institute Affiliated Group, Changsha, China
| | - Siyu Yang
- Department of Nursing Teaching and Research, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China
| | - Yan Tan
- Department of Gastrointestinal Surgery, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China
| | - Tongyu Wang
- Department of Nursing Teaching and Research, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China
| | - Hongyun Chen
- Department of Nursing Teaching and Research, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China
| | - Xuying Li
- Department of Nursing, Hunan Cancer Hospital/Affiliated Cancer Hospital of Xiangya nursing school of Central South University, Changsha, China/Xiangya Center for Evidence-Based Practice & Healthcare Innovation: A Joanna Briggs Institute Affiliated Group, Changsha, China
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11
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Pelzer F, Loef M, Martin DD, Baumgartner S. Cancer-related fatigue in patients treated with mistletoe extracts: a systematic review and meta-analysis. Support Care Cancer 2022; 30:6405-6418. [PMID: 35239008 PMCID: PMC9213316 DOI: 10.1007/s00520-022-06921-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 02/15/2022] [Indexed: 11/07/2022]
Abstract
PURPOSE Cancer-related fatigue remains one of the most prevalent and distressing symptoms experienced by cancer patients. Effective treatments for cancer-related fatigue are needed. The objective of this meta-analysis is to determine the impact of mistletoe extracts as a pharmacological treatment for the management of cancer-related fatigue. METHODS We included randomized clinical trials (RCTs) and non-randomized studies of interventions (NRSIs) in cancer patients. Inclusion criteria were cancer-related fatigue severity or prevalence as an outcome and testing of mistletoe extracts compared to control groups. We searched Medline (EuropePMC), Embase, the Cochrane Central Register of Controlled Trials, Clinicaltrials.gov, and opengrey.org through October 2020. We assessed the risk of bias using the Cochrane risk of bias tools for RCTs and NRSIs and conducted a meta-analysis. RESULTS We performed one meta-analysis with 12 RCTs, including 1494 participants, and one meta-analysis with seven retrospective NRSIs, including 2668 participants. Heterogeneity between the studies was high in both meta-analyses. Most studies had a high risk of bias. A random-effects model showed for RCTs a standardized mean difference of -0.48 (95% confidence interval -0.82 to -0.14; p = 0.006) and for NRSIs an odds ratio of 0.36 (95% confidence interval 0.20 to 0.66; p = 0.0008). CONCLUSION Treatment with mistletoe extracts shows a moderate effect on cancer-related fatigue of similar size to physical activity. These results need to be confirmed by more placebo-controlled trials. Future trials should investigate different treatment durations and their effect on cancer-related fatigue in post-treatment cancer survivors. TRIAL REGISTRATION This meta-analysis has been registered under the PROSPERO registration number CRD42020191967 on October 7, 2020.
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Affiliation(s)
- Florian Pelzer
- Institute of Integrative Medicine, Witten/Herdecke University, Witten, Germany.
- Society for Cancer Research, Arlesheim, Switzerland.
| | | | - David D Martin
- Institute of Integrative Medicine, Witten/Herdecke University, Witten, Germany
| | - Stephan Baumgartner
- Institute of Integrative Medicine, Witten/Herdecke University, Witten, Germany
- Society for Cancer Research, Arlesheim, Switzerland
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12
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Xiao P, Ding S, Duan Y, Li L, Zhou Y, Luo X, Xie J, Cheng AS. Effect of Light Therapy on Cancer-Related Fatigue: A Systematic Review and Meta-Analysis. J Pain Symptom Manage 2022; 63:e188-e202. [PMID: 34563631 DOI: 10.1016/j.jpainsymman.2021.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 09/13/2021] [Accepted: 09/14/2021] [Indexed: 12/19/2022]
Abstract
CONTEXT Light therapy is a non-pharmacological therapy that is currently being studied in cancer-related symptoms and is certificated as a low-risk intervention by FDA. Cancer-related fatigue (CRF) is the most common symptom reported by cancer patients. OBJECTIVE To examine the effectiveness of light therapy for CRF in cancer patients through a systematic review and meta-analysis. METHODS We conducted a systematic review of four electronic databases targeted randomized clinical trials evaluating light therapy for CRF (CRD42020215446), from inception to May 2021. The primary outcome was changes of CRF scores; secondary outcomes included depression, sleep, and quality of life (QoL). We quantitatively pooled outcomes using meta-analysis with random-effects models and assessed methodological bias. RESULTS We identified thirteen RCTs representing 551 cancer patients, encompassing breast (n = 5), ovarian or endometrial (n = 1), multiple myeloma (n = 1), lung (n = 1), or combined (n = 5) cancers. The comparison groups included dim light (n = 12) and waiting list (n = 1). Duration of intervention ranged from 1 to 12 weeks. Light intensities ranged from 417.9 to 12,000 lux. Light therapy was associated with a significant improvement in CRF (SMD = 0.45, P = 0.007), depression (SMD = -0.26, P = 0.03) and sleep difficulty (SMD = -2.46, P = 0.0006); a statistically non-significant trend was observed for QoL (SMD = 0.33, P = 0.09). Funnel plots for CRF suggest not significant publication bias. CONCLUSION Light therapy could be a feasible and effective option for improving CRF in cancer patients. Larger sample, rigor trials design and a standard protocol of intervention are needed to draw more conclusive conclusions.
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Affiliation(s)
- Panpan Xiao
- Xiangya Nursing School (P.X., L.L., Y.Z., X.L.), Central South University, Changsha, Hunan, China
| | - Siqing Ding
- Department of Nursing (S.D., J.X.), The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yinglong Duan
- Department of Emergency (Y.D.), The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Lijun Li
- Xiangya Nursing School (P.X., L.L., Y.Z., X.L.), Central South University, Changsha, Hunan, China
| | - Yi Zhou
- Xiangya Nursing School (P.X., L.L., Y.Z., X.L.), Central South University, Changsha, Hunan, China
| | - Xiaofei Luo
- Xiangya Nursing School (P.X., L.L., Y.Z., X.L.), Central South University, Changsha, Hunan, China
| | - Jianfei Xie
- Department of Nursing (S.D., J.X.), The Third Xiangya Hospital of Central South University, Changsha, Hunan, China.
| | - Andy Sk Cheng
- Department of Rehabilitation Sciences (A.S.K.C.), The Hong Kong Polytechnic University, Hong Kong, China
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13
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Sleep disturbance in cancer patients referred to an ambulatory integrative oncology consultation. Support Care Cancer 2021; 30:2417-2425. [PMID: 34762218 DOI: 10.1007/s00520-021-06668-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Sleep disturbance (SD) is highly prevalent in oncology and negatively affects quality of life and mortality. Evidence supports the use of integrative oncology (IO) practices to treat SD, but there is limited published data on the characteristics of SD and factors associated with SD in IO. We determined the prevalence, severity, and factors associated with SD among cancer patients seen in an ambulatory IO consultation. METHODS Patients with cancer referred for initial outpatient IO consultation in 2017 were eligible. Patient demographics, clinical characteristics, and patient-reported outcomes (Edmonton Symptom Assessment Scale (ESAS), Measure Yourself Concerns and Wellbeing (MYCaW), PROMIS-10) were retrospectively reviewed. RESULTS One thousand five hundred twenty patients were included in the analysis. The majority (70%) were women with breast cancer (42%). Nine hundred seventy-one (64%) patients reported significant SD with ESAS Sleep ≥ 4, yet only 11% expressed poor sleep as their primary or secondary concern for the IO consultation. The median SD (IQR) was 5 (3,7). ESAS scores for fatigue (adjusted OR 1.16; CI 1.07-1.26, p < 0.001), pain (adjusted OR 1.07; CI 1.00-1.15, p < 0.05), hot flashes (adjusted OR 1.14; CI 1.07-1.22, p < 0.001), well-being (adjusted OR 1.33; CI 1.22-1.46, p < 0.001), and psychological distress score (anxiety and depression) (adjusted OR 1.16; CI 1.01-1.11, p < 0.01) were independently associated with SD in multivariate analysis. Acupuncture was the most frequent intervention prescribed, 175 (35%). Other modalities included oncology massage (15%), health psychology (5%), and meditation (1%). CONCLUSIONS Although 64% of patients seeking IO consultation reported clinically significant SD, only 11% were seeking integrative approaches for managing SD. ESAS fatigue, hot flashes, well-being, and psychological symptoms were significantly associated with SD.
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14
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Balachandran DD, Miller MA, Faiz SA, Yennurajalingam S, Innominato PF. Evaluation and Management of Sleep and Circadian Rhythm Disturbance in Cancer. Curr Treat Options Oncol 2021; 22:81. [PMID: 34213651 DOI: 10.1007/s11864-021-00872-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/16/2022]
Abstract
OPINION STATEMENT Sleep and circadian rhythm disturbance are among the most commonly experienced symptoms in patients with cancer. These disturbances occur throughout the spectrum of cancer care from diagnosis, treatment, and long into survivorship. The pathogenesis of these symptoms and disturbances is based on common inflammatory pathways related to cancer and its' treatments. The evaluation of sleep and circadian disorders requires an understanding of how these symptoms cluster with other cancer-related symptoms and potentiate each other. A thorough evaluation of these symptoms and disorders utilizing validated diagnostic tools, directed review of clinical information, and diagnostic testing is recommended. Treatment of sleep and circadian disturbance in cancer patients should be based on the findings of a detailed evaluation, including specific treatment of primary sleep and circadian disorders, and utilize integrative and personalised management of cancer-related symptoms through multiple pharmacologic and non-pharmacologic modalities. Recognition, evaluation, and treatment of sleep and circadian rhythm disturbance in cancer may lead to improved symptom management, quality of life, and outcomes.
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Affiliation(s)
- Diwakar D Balachandran
- Department of Pulmonary Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street. Unit 1462, Houston, TX, 77030-4009, USA.
| | - Michelle A Miller
- Division of Health Sciences (Mental Health & Wellbeing), University of Warwick, Warwick Medical School, Gibbet Hill, Coventry, UK
| | - Saadia A Faiz
- Department of Pulmonary Medicine, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, 1400 Pressler Street. Unit 1462, Houston, TX, 77030-4009, USA
| | - Sriram Yennurajalingam
- Department of Palliative, Rehabilitation, and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Pasquale F Innominato
- North Wales Cancer Treatment Centre, Ysbyty Gwynedd, Betsi Cadwaladr University Health Board, Bangor, UK
- Cancer Chronotherapy Team, Warwick Medical School, Coventry, UK
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