Bedtime misalignment and progression of breast cancer

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.

Circadian rhythm disorders in patients with advanced cancer: a scoping review

Circadian rhythms can be demonstrated in several biomarkers and behavioural activities, with rhythmical patterns occurring roughly over a 24-h period. Circadian disorders occur in patients with cancer and may be associated with poor clinical outcomes. This scoping review aimed to identify circadian rhythm research and reporting practices, circadian rhythm patterns, circadian rhythm disorders, and relevant associations of circadian rhythm disorders in patients with advanced cancer. Studies involved adult patients with locally advanced or metastatic cancer and used objective measures of circadian rhythmicity. Two independent authors completed initial screening of title and abstracts, full text reviews, data extraction, and data checking. A total of 98 articles were highlighted in the scoping review, which utilised physical activity measures (actigraphy and polysomnography), biomarkers (cortisol and melatonin), or a combination. Several circadian rhythms are commonly disordered amongst patients with advanced cancer and have significant implications for symptom burden, quality of life, and survival. It remains unclear which patients are most at risk of a circadian rhythm disorder. Significant heterogeneity exists in research and reporting practices. Standardising this approach may address discrepancies in the current literature and allow for research to focus on the most relevant parameters and approaches to improving circadian rhythmicity.

Stress, Isolation, and Sleep Quality among Breast Cancer Survivors throughout the COVID-19 Pandemic: A Longitudinal Study in a Multi-Ethnic Cohort

Purpose

This study examined how stress, isolation, and sleep quality were impacted throughout the COVID-19 pandemic among breast cancer survivors (BCS).

Methods

BCS enrolled in the Chicago Multiethnic Epidemiologic Breast Cancer Cohort were surveyed in 2020, 2021, and 2022. An 11-item isolation/stress score was repeatedly measured in each survey and its changes were examined through mixed-effects models. Sleep quality was assessed in 2022 by the Insomnia Severity Index (ISI).

Results

In total, 1899 BCS responded (response rate: 62.8%), of whom 69% were White and 24% Black (median time since diagnosis: 5.1 years, IQR: 2.3-9.2). The isolation/stress score decreased significantly from 2020 to 2022 for White BCS, but only started declining for Black BCS in 2022. Consequently, although there were no significant racial difference in 2020, Black BCS had significantly higher isolation/stress scores in 2021 and 2022 (P < .01), while it became nonsignificant after adjusting for socioeconomic factors. BCS who were single, on Medicaid, without a high school degree, or with annual household income <$35,000 had significantly higher isolation/stress scores. Regarding sleep quality, 48% of BCS reported clinically-significant insomnia (ISI ≥ 8), and insomnia was strongly associated with higher isolation/stress scores (P-trend < .001).

Conclusions

Our findings suggested that the isolation/stress level improved among BCS as the pandemic subsided, but this positive trend was not observed equally across racial/ethnic groups potentially due to lack of resources.

Implications for Cancer Survivors

Additional resources, such as access to counseling services and sleep assistance programs, might support the post-pandemic recovery of undersevered BCS.

International e-Delphi Consensus Recommendations for the Assessment and Diagnosis of Circadian rest-Activity Rhythm Disorders (CARDs) in Patients with Cancer

PURPOSE

Circadian rest-Activity Rhythm Disorders (CARDs) are common in patients with cancer, particularly in advanced disease. CARDs are associated with increased symptom burden, poorer quality of life, and shorter survival. Research and reporting practices lack standardization, and formal diagnostic criteria do not exist. This electronic Delphi (e-Delphi) study aimed to formulate international recommendations for the assessment and diagnosis of CARDs in patients with cancer.

METHODS

An international e-Delphi was performed using an online platform (Welphi). Round 1 developed statements regarding circadian rest-activity rhythms, diagnostic criteria, and assessment techniques. Rounds 2 and 3 involved participants rating their level of agreement with the statements and providing comments until consensus (defined internally as 67%) and stability between rounds were achieved. Recommendations were then created and distributed to participants for comments before being finalized.

RESULTS

Sixteen participants from nine different clinical specialties and seven different countries, with 5-35 years of relevant research experience, were recruited, and thirteen participants completed all three rounds. Of the 164 generated statements, 66% achieved consensus, and responses were stable between the final two rounds.

CONCLUSIONS

The e-Delphi resulted in international recommendations for assessing and diagnosing CARDs in patients with cancer. These recommendations should ensure standardized research and reporting practices in future studies.

Circadian rhythm disrupting behaviours and cancer outcomes in breast cancer survivors: a systematic review

PURPOSE

Circadian rhythm disruptors (e.g., night-shift work) are risk factors for breast cancer, however studies on their association with prognosis is limited. A small but growing body of research suggests that altered sleep patterns and eating behaviours are potential mechanistic links between circadian rhythm disruptors and breast cancer. We therefore systematically summarised literature examining the influence of circadian rhythm disrupting behaviours on cancer outcomes in women with breast cancer.

METHODS

A systematic search of five databases from inception to January 2021 was conducted. Original research published in English, assessing the relationship between post-diagnosis sleep patters and eating behaviours, and breast cancer outcomes were considered. Risk of bias was assessed using the Newcastle-Ottawa Assessment Scale for Cohort Studies.

RESULTS

Eight studies published original evidence addressing sleep duration and/or quality (k = 7) and, eating time and frequency (k = 1). Longer sleep duration (≥ 9 h versus [referent range] 6-8 h) was consistently associated with increased risk of all outcomes of interest (HR range: 1.37-2.33). There was limited evidence to suggest that measures of better sleep quality are associated with lower risk of all-cause mortality (HR range: 0.29-0.97). Shorter nightly fasting duration (< 13 h versus ≥ 13 h) was associated with higher risk of all breast cancer outcomes (HR range: 1.21-1.36).

CONCLUSION

Our review suggests that circadian rhythm disrupting behaviours may influence cancer outcomes in women with breast cancer. While causality remains unclear, to further understand these associations future research directions have been identified. Additional well-designed studies, examining other exposures (e.g., light exposure, temporal eating patterns), biomarkers, and patient-reported outcomes, in diverse populations (e.g., breast cancer subtype-specific, socio-demographic diversity) are warranted.

The EASO New Investigator Award in Clinical Research 2021: Role of Chronotype in Obesity

BACKGROUND

Chronotype is the expression of the timing of circadian rhythmicity of a subject, and three categories of chronotype have been identified: morning, evening, and intermediate chronotype. Subjects with morning chronotype prefer to carry out most of their daily activities in the morning, while subjects with evening chronotype perform most of their daily activities in the second half of the day. Intermediate chronotype is in an intermediate position between the above reported categories. Recently, evening chronotype has been associated with an increased risk of developing chronic diseases. Thus, the aim of this manuscript was to review the current evidence on the role of chronotype categories on the risk of developing obesity and the most common obesity-related comorbidities (cardiometabolic and neoplastic complications).

SUMMARY

Subjects with evening chronotype have been reported to be at high risk of developing obesity, and this was mostly due to the tendency of these subjects to follow unhealthy lifestyle mostly characterized by sedentary behavior and high intake of unhealthy food. In addition, sleep disturbances are a common finding in subjects with evening chronotype that in turn could further contribute to the risk of obesity. The impairment of insulin sensitivity, melatonin, adiponectin, and clock genes function along with increase of leptin secretion detected in subjects with evening chronotype could also represent a favorable milieu for the onset of obesity-related cancer. The current evidence is limited to breast, prostate, and endometrial cancer.

KEY MESSAGES

The chronotype categories could be easy assessed in subjects with obesity and at the same time provide an important information on an additional risk factor predisposing to the onset of obesity-related comorbidities. Since chronotype could be potentially modified through a behavioral-driven approach thus potentiating the efficacy of anti-obesity treatment, the assessment of chronotype categories should be included in the management of obesity.

The longitudinal effects of chronotype on chemotherapy-induced nausea and vomiting in patients with breast cancer receiving neoadjuvant chemotherapy

OBJECTIVE

The object of this longitudinal cohort study was to investigate whether chronotype affects the incidence of chemotherapy-induced nausea and vomiting (CINV) among patients with breast cancer.

METHODS

The study included a total of 203 breast cancer patients who received neoadjuvant chemotherapy using a regimen of doxorubicin and cyclophosphamide with high emetogenicity. Patients received four cycles of chemotherapy in approximately three months. Patients completed questionnaires including the Munich Chronotype Questionnaire (MCTQ) before the first chemotherapy and the Multinational Association of Supportive Care in Cancer Antiemesis Tool (MAT) after each of the four chemotherapy sessions. To confirm the effect of chronotype on CINV during the four cycles, we performed statistical analyses using a generalized estimating equation (GEE).

RESULTS

CINV occurred in 108 (53.2%), 112 (55.2%), 102 (50.3%), and 62 (30.5%) patients during four cycles of treatment. In the GEE approach, late and early chronotypes (vs. intermediate chronotype) were associated with an increased risk of CINV (late chronotype: odds ratio [OR], 2.06; 95% confidence interval [CI], 1.41-2.99; p < 0.001, early chronotype: OR, 1.84; CI, 1.25-2.73; p = 0.002), which remained significant even after adjusting for age, BMI, antiemetic treatment, history of nausea and vomiting, anxiety, and sleep quality.

CONCLUSION

Chronotype affected CINV across the four cycles of neoadjuvant chemotherapy in patients with breast cancer, suggesting the need to consider chronotype in predicting and managing CINV.

A practical nutritional guideline to manage neuroendocrine neoplasms through chronotype and sleep

Chronotype is the attitude of subjects to carry out their daily activities mainly in the morning ("lark") or in the evening ("owl"). The intermediate chronotype is located between these two categories. It has been demonstrated that chronotype can influence the incidence, course and response to treatments of tumors. In particular patients diagnosed with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs) and evening chronotype are characterized by unhealthy lifestyle, obesity, metabolic syndrome, a worsen cardiometabolic profile, a poor prognosis with a progressive disease and the development of metastasis. In addition, evening chronotype has been associated with sleep disturbances, which in turn have been related to tumor development and progression of tumors. There is a strict connection between sleep disturbances and NENs because of the hyperactivation of proangiogenic factors that caused aberrant neoangiogenesis. A nutritional tailored approach could represent a tool to align subjects with evening chronotype to physiological biological rhythms based on the properties of some macro and micronutrients of being substrate for melatonin synthesis. Thus, we aimed to provide an overview on the association of chronotype categories and sleep disturbances with NENs and to provide nutritional advices to manage subjects with NENs and these disturbances of circadian rhythm.

Morning Chronotype Decreases the Risk of Chemotherapy-Induced Peripheral Neuropathy in Women With Breast Cancer

BACKGROUND

The purpose of this longitudinal prospective cohort study was to investigate the role of chronotype in the incidence of chemotherapy-induced peripheral neuropathy (CIPN) among women with breast cancer.

METHODS

We recruited women with breast cancer awaiting adjuvant chemotherapy, including four cycles of docetaxel. Participants reported peripheral neuropathy symptoms of numbness/tingling at the baseline, and at 4weeks after completion of chemotherapy. Candidate psychiatric factors associated with CIPN were assessed at the baseline, using the Composite Scale of Morningness, the Pittsburgh Sleep Quality Index, and the Hospital Anxiety and Depression Scale. To examine the association between chronotype and CIPN, we built logistic regression models, adjusting for demographic, clinical, and other psychiatric variables.

RESULTS

Among 48 participants, 29 participants developed CIPN. The morning chronotype was inversely associated with CIPN (odds ratio, 0.06; confidence interval, 0.01-0.74; P = 0.028) after adjusting for age, BMI, education, type of operation, alcohol use, smoking, sleep quality, depression, and anxiety.

CONCLUSION

Our results suggest that the morning chronotype is a protective factor against the development of CIPN in patients with breast cancer who were treated with docetaxel.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01887925.

Relationship of Circadian Rhythm and Psychological Health in Adolescents and Young Adults With Cancer

BACKGROUND

Evidence shows that adolescent and young adult (AYA) cancer patients have an increasing survival rate but experience psychological distress and circadian rhythm dysregulation. Little is known about the effect of circadian rhythm on psychological distress.

OBJECTIVE

To investigate the type of circadian rhythm in Chinese AYA cancer survivors and examine the associations among chronotype, demographic characteristics, psychological distress, anxiety and depression, character strengths, and medical coping in this group.

METHODS

This cross-sectional study enrolled 800 AYA cancer participants, 728 of whom completed the Chinese version of the Morningness-Eveningness Questionnaire, the Distress Thermometer, the Hospital Anxiety and Depression Scale, the Three-Dimensional Inventory of Character Strengths, and the Medical Coping Modes Questionnaire.

RESULTS

Evening- and morning-type participants accounted for 35.0% and 19.1%, respectively, among participants, which was significantly higher than those found in the general population. The prevalence of psychological distress was 84.9% among AYA cancer participants. Exercise, Distress Thermometer, and depression were important predictive factors for the circadian rhythm.

CONCLUSIONS

Circadian rhythm disorder and psychological distress were common among AYA cancer survivors. Evening-type participants performed worse on character strength, confrontation, and avoidance of medical coping.

IMPLICATIONS FOR PRACTICE

Healthcare professionals need to understand the circadian rhythm and psychological health of AYA cancer survivors. Psychological rehabilitation guidance, especially within the 6 months after diagnosis, may benefit AYA survivors according to their chronotype. Character strengths can also be used during rehabilitation to properly guide AYA survivors.

Murata R, Pereira LJ. Association between Chronotype and Nutritional, Clinical and Sociobehavioral Characteristics of Adults Assisted by a Public Health Care System in Brazil

Chronotype (CT) has been associated with predisposition to chronic noncommunicable diseases (CNCDs), such as diabetes mellitus and obesity. However, the effects of CT on individuals assisted by public health systems (PHSs) in middle-up economies are still poorly explored. The objective of this study was to evaluate the relationship between CT and clinical, sociobehavioral and nutritional aspects in adults assisted by a PHS in Brazil. This is a population-based cross-sectional study. The sample consisted of 380 individuals, selected through probabilistic sampling by clusters, in all health units in a city of approximately 100 thousand inhabitants. Data collection was performed during home visits, by means of general and nutritional interviews, anthropometric measurements and the Morningness-Eveningness Questionnaire (MEQ). Statistical analysis comprised chi-square test and principal component analysis (CPA) followed by Fisher's discriminant analysis to determine aspects associated with each CT (morning, evening or intermediate). With the aim of explaining the variation in the CT scores, the consumption of micronutrients (corrected to the total energy intake) and other individual and sociodemographic variables were used as explanatory factors in the adjustment of a linear regression model. The morning group was characterized by older men, with less than eight years of schooling, with low body mass index (BMI) and with low intake of omega-6, omega-3, sodium, zinc, thiamine, pyridoxine and niacin. The evening group, on the other hand, was composed of younger individuals, with a high consumption of these same nutrients, with high BMI and a higher frequency of heart diseases (p < 0.05). It was concluded that most morning CT individuals were elderly thin males with lower consumption of omega-6 and -3, sodium, zinc, thiamine, pyridoxine and niacin, whereas evening individuals were younger, had higher BMI and had higher consumption of the studied micronutrients. The identification of circadian and behavioral risk groups can help to provide preventive and multidisciplinary health promotion measures.

Genetics of the human circadian clock and sleep homeostat

Timing and duration of sleep are controlled by the circadian system, which keeps an ~24-h internal rhythm that entrains to environmental stimuli, and the sleep homeostat, which rises as a function of time awake. There is a normal distribution across the population in how the circadian system aligns with typical day and night resulting in varying circadian preferences called chronotypes. A portion of the variation in the population is controlled by genetics as shown by the single-gene mutations that confer extreme early or late chronotypes. Similarly, there is a normal distribution across the population in sleep duration. Genetic variations have been identified that lead to a short sleep phenotype in which individuals sleep only 4-6.5 h nightly. Negative health consequences have been identified when individuals do not sleep at their ideal circadian timing or are sleep deprived relative to intrinsic sleep need. Whether familial natural short sleepers are at risk of the health consequences associated with a short sleep duration based on population data is not known. More work needs to be done to better assess for an individual's chronotype and degree of sleep deprivation to answer these questions.

Chronotype and postmenopausal breast cancer risk among women in the California Teachers Study

Chronotype is the behavioral manifestation of an individual's underlying circadian rhythm, generally characterized by one's propensity to sleep at a particular time during the 24 hour cycle. Evening chronotypes ("night owls") generally suffer from worse physical and mental health compared to morning chronotypes ("morning larks") - for reasons that have yet to be explained. One hypothesis is that evening chronotypes may be more susceptible to circadian disruption, a condition where the coordinated timing of biologic processes breaks down. The role of chronotype as an independent or modifying risk factor for cancer has not been widely explored. The objective of the current study was to evaluate the risk of breast cancer associated with chronotype in a case-control study nested within the California Teachers Study (CTS) cohort. The study population consisted of 39686 post-menopausal CTS participants who provided information on chronotype by completing a questionnaire in 2012-2013. 2719 cases of primary invasive breast cancer diagnosed from 1995/1996 through completion of the chronotype questionnaire were identified by linkage of the CTS to the California Cancer Registry. 36967 CTS participants who had remained cancer-free during this same time period served as controls. Chronotype was ascertained by responses to an abbreviated version of the Horne-Ostberg Morningness-Eveningness Questionnaire (MEQ) and was characterized into five categories: definite morning, more morning than evening, neither morning or evening, more evening than morning, definite evening. Multivariable unconditional logistic regression analyses were performed to estimate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for each of the chronotypes, adjusted for established breast cancer risk factors. Compared to definite morning types, definite evening types had an increased risk of breast cancer with elevated ORs that were statistically significant in both the crude (OR = 1.24, 95% CI: 1.10-1.40) and fully-adjusted models (OR = 1.20, 95% CI: 1.06-1.35). The risk estimates in the fully-adjusted model for all other chronotypes did not significantly differ from one. These results suggest that evening chronotype may be an independent risk factor for breast cancer among a population of women who are not known to have engaged in any substantial night shift work. Further research in other populations of non-shift workers is warranted.

The day after: correlates of patient-reported outcomes with actigraphy-assessed sleep in cancer patients at home (inCASA project)

Subjective sleep assessment in cancer patients poorly correlates with actigraphy parameters that usually encompass multiple nights. We aimed to determine the objective actigraphy measures that best correlated with subjective sleep ratings on a night-by-night basis in cancer patients. Thirty-one cancer patients daily self-rated sleep disturbances using the single dedicated item of the MD Anderson Symptom Inventory (0-10 scale) with 18 other items, and continuously wore a wrist actigraph for 30 days. Objective sleep parameters were computed from the actigraphy nighttime series, and correlated with subjective sleep disturbances reported on the following day, using repeated measures correlations. Multilevel Poisson regression analysis was performed to identify the objective and subjective parameters that affected subjective sleep rating. Poor subjective sleep score was correlated with poor sleep efficiency (rrm = -0.13, p = 0.002) and large number of wake episodes (rrm = 0.12, p = 0.005) on the rated night. Multilevel analysis demonstrated that the expected sleep disturbance score was affected by the joint contribution of the wake episodes (exp(β) = 1.01, 95% confidence interval = 1.00 to 1.02, p = 0.016), fatigue (exp(β) = 1.35, 95% confidence interval = 1.15 to 1.55, p < 0.001) and drowsiness (exp(β) = 1.70, 95% confidence interval = 1.19 to 2.62, p = 0.018), self-rated the following evening, and sleep disturbance experienced one night before (exp(β) = 1.77, 95% confidence interval = 1.41 to 2.22, p < 0.001). The night-by-night approach within a multidimensional home tele-monitoring framework mainly identified the objective number of wake episodes computed from actigraphy records as the main determinant of the severity of sleep complaint in cancer patients on chemotherapy. This quantitative information remotely obtained in real time from cancer patients provides a novel framework for streamlining and evaluating interventions toward sleep improvement in cancer patients.

Joint effects of multiple sleep characteristics on breast cancer progression by menopausal status

OBJECTIVES

Sleep has been closely linked to breast cancer risk. However, the association between sleep and breast cancer prognosis remains unclear. The aim of this study was to evaluate the separate and joint effects of multiple sleep characteristics on breast cancer prognosis among Chinese women.

METHODS

A total of 1580 breast cancer patients were recruited between October 2008 and December 2014 and followed up until December 31, 2017 in Guangzhou. Multivariate Cox models were conducted to estimate the hazard ratios (HR) and 95% confidence intervals (95%CI) for breast cancer prognosis in association with sleep characteristics.

RESULTS

Long sleep duration at night (>9 h) (HR = 2.33, 95%CI: 1.01-5.42), poor sleep quality (HR = 3.08, 95%CI: 1.74-5.47), and impaired daytime function (HR = 2.49, 95%CI: 1.65-3.79) after diagnosis were associated with an increased risk of breast cancer progression. Both short sleep duration (<6 h) (HR = 2.00, 95%CI: 1.06-3.77, P_interaction = 0.011) and long sleep duration (>9 h) (HR = 4.69, 95%CI: 1.31-16.78, P_interaction = 0.187) increased the progression risk only among patients with impaired but not normal daytime function. In addition, daytime napping significantly modified the effect of short sleep duration on the progression (HR = 3.55, 0.59, 95%CI: 1.55-7.97, 0.23-1.53 for patients without and with daytime napping, respectively, P_interaction = 0.005). Stratification results suggested that the associations were more evident among pre-menopausal patients, although no significant interaction was observed.

CONCLUSION

Our findings suggested that inadequate sleep duration to feel one's best and poor sleep quality after diagnosis were associated with an increased risk of breast cancer progression, particularly for pre-menopausal women.

Daily Patterns of Accelerometer Activity Predict Changes in Sleep, Cognition, and Mortality in Older Men

Background

There is growing interest in the area of "wearable tech" and its relationship to health. A common element of many of these devices is a triaxial accelerometer that can yield continuous information on gross motor activity levels; how such data might predict changes in health is less clear.

Methods

We examined accelerometry data from 2,976 older men who were part of the Osteoporotic Fractures in Men (MrOS) study. Using a shape-naive technique, functional principal component analysis, we examined the patterns of motor activity over the course of 4-7 days and determined whether these patterns were associated with changes in polysomnographic-determined sleep and cognitive function (Trail Making Test-Part B [Trails B], Modified Mini-Mental State Examination [3MS]), as well as mortality over 6.5-8 years of follow-up.

Results

In comparing baseline to 6.5 years later, multivariate modeling indicated that low daytime activity at baseline was associated with worsening of sleep efficiency (p < .05), more wake after sleep onset (p < .05), and a decrease in cognition (Trails B; p < .001), as well as a 1.6-fold higher rate of all-cause mortality (hazard ratio = 1.64 [1.34-2.00]). Earlier wake and bed times were associated with a decrease in cognition (3MS; p < .05). Having a late afternoon peak in activity was associated with a 1.4-fold higher rate of all-cause mortality (hazard ratio = 1.46 [1.21-1.77]). Those having a longer duration of their daytime activity with a bimodal activity pattern also had over a 1.4-fold higher rate of cardiovascular-related mortality (hazard ratio = 1.42 [1.02-1.98]).

Conclusions

Patterns of daily activity may be useful as predictive biomarkers for changes in clinically relevant outcomes, including mortality and changes in sleep and cognition in older men.

Chronotype Differences in Health Behaviors and Health-Related Quality of Life: A Population-Based Study Among Aged and Older Adults

This study investigates health behaviors, health-related quality of life (HRQOL) and sleep among chronotypes in a community-based sample (n = 2,976). Analysis of covariance indicated evening types (E-types) had a significantly higher percentage of current smokers and more sleep-interfering behaviors compared to intermediate and morning types (M-type), and also lower physical activity and more sleep disturbance compared to M-types. E-types also had worse mental HRQOL compared to both chronotypes, and worse physical HRQOL compared to M-types. Exploratory analyses indicated E-types consumed more caffeinated beverages at night, smoked or ate heavy meals before bedtime, kept irregular sleep-wake schedules, and took more naps. Mediational analyses indicated that sleep-interfering behavior partially mediated the relationship between chronotype and sleep disturbance, and physical activity partially mediated the relationship between chronotype and mental HRQOL. E-types had more unhealthy behaviors, which may subsequently place them at higher risk for health problems.

Late chronotypes are associated with neoadjuvant chemotherapy-induced nausea and vomiting in women with breast cancer

Neoadjuvant chemotherapy, that is, the administration of chemotherapy before surgery, has been commonly used for locally advanced breast cancer to improve the surgical outcomes and increase the opportunity for breast-conserving therapy. Women with breast cancer often receive an anthracycline-based regimen as the neoadjuvant chemotherapy, which is associated with a high risk of emesis. Despite the development of novel antiemetics, chemotherapy-induced nausea and vomiting (CINV) has been commonly reported as a major adverse effect, affecting the quality of life of the patients. However, the factors predicting CINV in women with breast cancer undergoing neoadjuvant chemotherapy remain unclear. In this single-institution, prospective, observational study conducted at an outpatient cancer centre in the Republic of Korea from November 2013 to March 2016, we analysed women with breast cancer who planned to be treated with neoadjuvant chemotherapy before surgery. Candidate factors associated with CINV were assessed before neoadjuvant chemotherapy using the Munich Chronotype Questionnaire, Pittsburgh Sleep Quality Index and Hospital Anxiety and Depression Scale. CINV was assessed after chemotherapy by using the Multinational Association of Supportive Care in Cancer Antiemesis Tool. Of a total of 143 participants, 7 patients were lost to follow-up and 2 patients were excluded due to changes in their treatment plan; thus, 134 patients were finally included in the analyses. Overall, 48.5% of the participants experienced CINV, with delayed CINV prevalence (42.5%) being more common than acute (39.6%). In the univariate analyses, overall CINV was significantly associated with late chronotypes (odds ratio [OR], 3.49; 95% confidence interval [CI], 1.37-8.87; p = 0.009), a history of nausea/vomiting (OR, 2.19; 95% CI, 1.10-4.37; p = 0.026) and anxiety (OR, 2.25; 95% CI, 1.05-4.81; p = 0.036). In the multivariate analyses, late chronotypes (OR, 3.53; 95% CI, 1.27-9.79; p = 0.015) and a history of nausea/vomiting (OR, 2.83; 95% CI, 1.31-6.13; p = 0.008) remained significantly associated with CINV. In conclusion, in women with breast cancer undergoing neoadjuvant chemotherapy before surgery, late chronotypes were found to have an increased risk of CINV; these data suggest that clinicians need to assess and consider the chronotype in the management of CINV.

Sleep duration and breast cancer prognosis: perspectives from the Women's Healthy Eating and Living Study

PURPOSE

To examine whether baseline sleep duration or changes in sleep duration are associated with breast cancer prognosis among early-stage breast cancer survivors in the multi-center Women's Healthy Eating and Living Study.

METHODS

Data were collected from 1995 to 2010. Analysis included 3047 women. Sleep duration was self-reported at baseline and follow-up intervals. Cox proportional hazard models were used to investigate whether baseline sleep duration was associated with breast cancer recurrence, breast cancer-specific mortality, and all-cause mortality. Time-varying models investigated whether changes in sleep duration were associated with breast cancer prognosis.

RESULTS

Compared to women who slept 7-8 h/night at baseline, sleeping ≥9 h/night was associated with a 48% increased risk of breast cancer recurrence (Hazard ratio [HR] 1.48, 95% Confidence interval [CI] 1.01, 2.00), a 52% increased risk of breast cancer-specific mortality (HR 1.52, 95% CI 1.09, 2.13), and a 43% greater risk of all-cause mortality (HR 1.43, 95% CI 1.07, 1.92). Time-varying models showed analogous increased risk in those who inconsistently slept ≥9 h/night (all P < 0.05), but not in those who consistently slept ≥9 h/night.

CONCLUSIONS

Consistent long or short sleep, which may reflect inter-individual variability in the need for sleep, does not appear to influence prognosis among early-stage breast cancer survivors.

Sleep and Breathing … and Cancer?

Sleep, like eating and breathing, is an essential part of the daily life cycle. Although the science is still emerging, sleep plays an important role in immune, cardiovascular, and neurocognitive function. Despite its great importance, nearly 40% of U.S. adults experience problems with sleep ranging from insufficient total sleep time, trouble initiating or maintaining sleep (Insomnia), circadian rhythm disorders, sleep-related movement disorders, and sleep-related breathing disorders such as obstructive sleep apnea (OSA). Herein, we discuss new evidence that suggests that sleep may also affect carcinogenesis. Specifically, we review recent epidemiologic data suggesting links between cancer and OSA. As OSA is a common, underdiagnosed, and undertreated condition, this has public health implications. Intriguing animal model data support a link between cancer and sleep/OSA, although mechanisms are not yet clear. Leaders in the fields of sleep medicine, pulmonology, and oncology recently met to review and discuss these data, as well as to outline future directions of study. We propose a multidisciplinary, three-pronged approach to studying the associations between cancer and sleep, utilizing mutually interactive epidemiologic studies, preclinical models, and early-phase clinical trials. Cancer Prev Res; 9(11); 821-7. ©2016 AACR.

The Pathophysiologic Role of Disrupted Circadian and Neuroendocrine Rhythms in Breast Carcinogenesis

Most physiological processes in the brain and body exhibit daily (circadian) rhythms coordinated by an endogenous master clock located in the suprachiasmatic nucleus of the hypothalamus that are essential for normal health and functioning. Exposure to sunlight during the day and darkness at night optimally entrains biological rhythms to promote homeostasis and human health. Unfortunately, a major consequence of the modern lifestyle is increased exposure to sun-free environments during the day and artificial lighting at night. Additionally, behavioral disruptions to circadian rhythms (ie, repeated transmeridian flights, night or rotating shift work, or sleep disturbances) have a profound influence on health and have been linked to a number of pathological conditions, including endocrine-dependent cancers. Specifically, night shift work has been identified as a significant risk factor for breast cancer in industrialized countries. Several mechanisms have been proposed by which shift work-induced circadian disruptions promote cancer. In this review, we examine the importance of the brain-body link through which circadian disruptions contribute to endocrine-dependent diseases, including breast carcinogenesis, by negatively impacting neuroendocrine and neuroimmune cells, and we consider preventive measures directed at maximizing circadian health.

Dosing-Time Makes the Poison: Circadian Regulation and Pharmacotherapy

Daily rhythms in physiology significantly modulate drug pharmacokinetics and pharmacodynamics according to the time-of-day, a finding that has led to the concept of chronopharmacology. The importance of biological clocks for xenobiotic metabolism has gained increased attention with the discovery of the molecular circadian clockwork. Mechanistic understanding of the cell-autonomous molecular circadian oscillator and the circadian timing system as a whole has opened new conceptual and methodological lines of investigation to understand first, the clock's impact on a specific drug's daily variations or the effects/side effects of environmental substances, and second, how clock-controlled pathways are coordinated within a given tissue or organism. Today, there is an increased understanding of the circadian modulation of drug effects. Moreover, several molecular strategies are being developed to treat disease-dependent and drug-induced clock disruptions in humans.

Sleep-deprivation reduces NK cell number and function mediated by β-adrenergic signalling

Reduction of sleep time triggers a stress response, leading to augmented levels of glucocorticoids and adrenaline. These hormones regulate components of the innate immune system such as natural killer (NK) and NKT cells. In the present study, we sought to investigate whether and how stress hormones could alter the population and function of NK and NKT cells of mice submitted to different lengths of paradoxical sleep deprivation (PSD, from 24 to 72 h). Results showed that 72h of PSD decreased not only NK and NKT cell counts, but also their cytotoxic activity against B16F10 melanoma cells in vitro. Propranolol treatment during PSD reversed these effects, indicating a major inhibitory role of beta-adrenergic receptors (β-AR) on NK cells function. Moreover, both corticosterone plasma levels and expression of beta 2-adrenergic receptors (β2-AR) in NK cells increased by 48 h of PSD. In vitro incubation of NK cells with dexamethasone augmented the level of β2-AR in the cell surface, suggesting that glucocorticoids could induce β2-AR expression. In summary, we propose that reduction of NK and NKT cell number and cytotoxic activity appears to be mediated by glucocorticoids-induced increased expression of β2-AR in these cells.

How sleep and wakefulness influence circadian rhythmicity: effects of insufficient and mistimed sleep on the animal and human transcriptome

The mammalian circadian system is a multi-oscillator, hierarchically organised system where a central pacemaker synchronises behavioural, physiological and gene expression rhythms in peripheral tissues. Epidemiological studies show that disruption of this internal synchronisation by short sleep and shift work is associated with adverse health outcomes through mechanisms that remain to be elucidated. Here, we review recent animal and human studies demonstrating the profound effects of insufficient and mistimed sleep on the rhythms of gene expression in central and peripheral tissues. In mice, sleep restriction leads to an ~80% reduction in circadian transcripts in the brain and profound disruption of the liver transcriptome. In humans, sleep restriction leads to a 1.9% reduction in circadian transcripts in whole blood, and when sleep is displaced to the daytime, 97% of rhythmic genes become arrhythmic and one-third of all genes show changes in temporal expression profiles. These changes in mice and humans include a significant reduction in the circadian regulation of transcription and translation and core clock genes in the periphery, while at the same time rhythms within the suprachiasmatic nucleus are not disrupted. Although the physiological mediators of these sleep disruption effects on the transcriptome have not been established, altered food intake, changes in hormones such as cortisol, and changes in body and brain temperature may play important roles. Processes and molecular pathways associated with these disruptions include metabolism, immune function, inflammatory and stress responses, and point to the molecular mechanisms underlying the established adverse health outcomes associated with short sleep duration and shift work, such as metabolic syndrome and cancer.

The associations of bedtime, nocturnal, and daytime sleep duration with bone mineral density in pre- and post-menopausal women

To explore the association of sleep patterns with bone mineral density (BMD) in pre- and post-menopausal women, we used a questionnaire to evaluate the sleep patterns and performed calcaneal quantitative ultrasound to estimate BMD, in 6,510 women aged 40 years or older, from June to November 2011 in Nanjing City. We found a 1.7-fold risk of osteoporosis in post-menopausalwomen with bedtime of ≥0:00 am (OR = 1.69, 95 % CI 1.39-2.13), compared to those whose bedtime of <0:00 am. post-menopausalwomen with excessive total sleep (>10 h vs. 8-9 h, OR = 1.54, 95 % CI 1.05-2.02) were shown to have a higher risk of osteoporosis, however, this high risk was not detected in those with excessive nocturnal sleep (>10 h vs. 8-9 h, OR = 0.85, 95 % CI 0.62-1.30). By contrast, post-menopausalwomen with inadequate nocturnal sleep (≤7 h vs. 8-9 h, OR = 1.68, 95 % CI 1.32-2.75), excessive daytime sleep (≥180 min vs. 0 min, OR = 1.52, 95 % CI 1.08-2.13), and noontime nap (>60 min vs. 0 min: OR = 1.37, 95 % CI 1.06-1.76) were demonstrated to have higher risk of bone loss. Nevertheless, these associations were not found in premenopausal women. We conclude that delayed bedtime, nocturnal sleep deprivation, excessive daytime sleep, and noontime nap, but not reduced total sleep duration, could promote bone loss in post-menopausalwomen, which might be related to circadian rhythm disturbances. However, they have limited influences to BMD in women who were still in menstruating. Mechanism responsible for the phenomena warrants further investigation.

Habitual sleep-wake behaviors and lifestyle as predictors of diurnal cortisol patterns in young breast cancer survivors: a longitudinal study

OBJECTIVE

This study aimed to identify predictors of changes in diurnal cortisol patterns during the 8-month follow up period for young breast cancer survivors. Among the potential predictors were tumor size, lymph node metastasis, changes in sleep problems, habitual time of awakening and bedtime, physical activity levels, body mass index (BMI), and depressive levels across 8 months.

METHODS

The participants were 62 breast cancer women who were aged 40 years and below, and had completed active breast cancer treatment. The longitudinal data were collected at four points: baseline assessment (T0) and three follow-ups after baseline: T1 (in the 2nd month), T2 (in the 5th month), and T3 (in the 8th month). The participants collected their salivary cortisol at home at six time points: upon waking, 30 and 45min after waking, and at 1200h, 1700h, and 2100h. They also completed several questionnaires: the Medical Outcomes Study Sleep scale; the Beck Depression Inventory-II, physical activity levels on a 10-point scale, time of going to bed, time of awakening, and total sleep hours.

RESULTS

This study found that the main predictors of changes toward flatter diurnal cortisol patterns during the 8-month follow ups were greater tumor sizes, increases of BMI scores, and habitually later times of awakening.

CONCLUSIONS

While greater tumor sizes represent biological vulnerability of disruption of cortisol circadian rhythm, maintaining an appropriate BMI and good sleep habits could be a protective factor for normal cortisol regulation, which likely helps to reduce early mortality in young breast cancer survivors.

Deregulation of the circadian clock constitutes a significant factor in tumorigenesis: a clockwork cancer. Part II. In vivo studies

The uneventful progression through the cell cycle is closely associated with the rhythm set by the circadian clock machinery, with the S-phase of the cell cycle typically occurring at night. Presence of unrepaired DNA damage may reset the phase of the circadian clock, providing opportunities for damage assessment, repair and/or the induction of pro-apoptotic pathways. The core proteins of the circadian clock regulate directly or indirectly a significant number of genes coding for proteins involved in checkpoint transition, cell proliferation and programmed cell death. Disruption of the circadian rhythm may increase the risk for some multifactorial diseases and conditions, including glucose intolerance, cardiovascular disease and various common cancers. In patients with cancer, chronic circadian misalignment may stimulate the growth of tumours and may modify the outcomes of anticancer therapy. Knowledge about the role of physiological rhythms in human disease may contribute to the field of individualized medicine, specifically, in risk assessment and prognostication of the outcomes in patients with multifactorial disease.

The circadian timing system in clinical oncology

The circadian timing system (CTS) controls several critical molecular pathways for cancer processes and treatment effects over the 24 hours, including drug metabolism, cell cycle, apoptosis, and DNA damage repair mechanisms. This results in the circadian time dependency of whole-body and cellular pharmacokinetics and pharmacodynamics of anticancer agents. However, CTS robustness and phase varies among cancer patients, based on circadian monitoring of rest- activity, body temperature, sleep, and/or hormonal secretion rhythms. Circadian disruption has been further found in up to 50% of patients with metastatic cancer. Such disruption was associated with poor outcomes, including fatigue, anorexia, sleep disorders, and short progression-free and overall survival. Novel, minimally invasive devices have enabled continuous CTS assessment in non-hospitalized cancer patients. They revealed up to 12-hour differences in individual circadian phase. Taken together, the data support the personalization of chronotherapy. This treatment method aims at the adjustment of cancer treatment delivery according to circadian rhythms, using programmable-in-time pumps or novel release formulations, in order to increase both efficacy and tolerability. A fixed oxaliplatin, 5-fluorouracil and leucovorin chronotherapy protocol prolonged median overall survival in men with metastatic colorectal cancer by 3.3 months as compared to conventional delivery, according to a meta-analysis (P=0.009). Further analyses revealed the need for the prevention of circadian disruption or the restoration of robust circadian function in patients on chronotherapy, in order to further optimize treatment effects. The strengthening of external synchronizers could meet such a goal, through programmed exercise, meal timing, light exposure, improved social support, sleep scheduling, and the properly timed administration of drugs that target circadian clocks. Chrono-rehabilitation warrants clinical testing for improving quality of life and survival in cancer patients.

Circadian misalignment and health

Circadian rhythms are near 24-h patterns of physiology and behaviour that are present independent of external cues including hormones, body temperature, mood, and sleep propensity. The term 'circadian misalignment' describes a variety of circumstances, such as inappropriately timed sleep and wake, misalignment of sleep/wake with feeding rhythms, or misaligned central and peripheral rhythms. The predominance of early research focused on misalignment of sleep to the biological night. However, discovery of clock genes and the presence of peripheral circadian oscillators have expanded the definitions of misalignment. Experimental studies conducted in animal models and humans have provided evidence of potential mechanisms that link misalignment to negative outcomes. These include dysregulation of feeding behaviours, changes in appetite stimulating hormones, glucose metabolism and mood. This review has two foci: (1) to describe how circadian misalignment has been defined and evaluated in laboratory and field experiments, and (2) to describe evidence linking different types of circadian misalignment to increased risk for physical (cardiovascular disease, diabetes, obesity, cancer) and psychiatric (depression, bipolar, schizophrenia, attention deficit) disorders. This review will describe the role of circadian misalignment as a risk factor for disease in the general population and in clinical populations, including circadian rhythm sleep disorders and psychiatric disorders.