Evaluating chronotypically tailored light therapy for breast cancer survivors: Preliminary findings on fatigue and disrupted sleep

More than one-third of cancer survivors experience significant residual symptoms after treatment completion. Fatigue and sleep disruption often co-occur and exacerbate each other. The purpose of this preliminary analysis was to examine the effect of a chronotypically tailored light therapy on fatigue and sleep disruption in female survivors 1-3 years post-completion of chemotherapy and/or radiation for stage I to III breast cancer. The data for this analysis were collected as part of an ongoing two-group randomized controlled trial (NCT03304587). Participants were randomized to receive either bright blue-green light (experimental) or dim red light (control). Light therapy was self-administered using a light visor cap at home. Both groups received 30-min daily light therapy for 14 consecutive days either between 19:00 and 20:00 h (for morning chronotypes) or within 30 min of waking in the morning (for evening chronotypes). Fatigue and sleep quality were self-reported using the Patient-Reported Outcomes Measurement Information System (PROMIS)-Fatigue, PROMIS-Sleep Disturbance, Pittsburgh Sleep Quality Index, and a daily log before (pre-test) and following the light intervention (post-test). Linear mixed model analysis or generalized estimating equations examined group difference overtime adjusting for pre-test scores. No between-group differences were found. However, after adjusting for the baseline fatigue, the experimental group reported significant decreases in fatigue (p < .001) and sleep disturbance (p = .024) overtime. The experimental group also reported significantly better subjective sleep quality after 14 d of light therapy (p = .017). Positive trends in sleep latency, sleep duration, night-time awakenings, and early morning awakenings were also observed. Unexpectedly, sleep disturbance significantly decreased in the control group (p = .030). Those who received dim light control reported significantly shorter sleep latency (p = .002), longer total sleep time (p = .042), and greater habitual sleep efficiency (p = .042). These findings suggest that bright light therapy significantly improved post-treatment fatigue and subjective sleep quality in breast cancer survivors. Although it remains to be confirmed, the findings additionally show unexpected benefits of dim light on sleep. Properly timed light exposure may optimize the therapeutic effect and can be the key for successful light therapy. How the administration timing coupled with wavelengths (short vs. long) and intensity of light affecting fatigue and disrupted sleep requires further investigation.

The nested structure of cancer symptoms. Implications for analyzing co-occurrence and managing symptoms

OBJECTIVE

Although many cancer patients experience multiple concurrent symptoms, most studies have either focused on the analysis of single symptoms, or have used methods such as factor analysis that make a priori assumptions about how the data is structured. This article addresses both limitations by first visually exploring the data to identify patterns in the co-occurrence of multiple symptoms, and then using those insights to select and develop quantitative measures to analyze and validate the results.

METHODS

We used networks to visualize how 665 cancer patients reported 18 symptoms, and then quantitatively analyzed the observed patterns using degree of symptom overlap between patients, degree of symptom clustering using network modularity, clustering of symptoms based on agglomerative hierarchical clustering, and degree of nestedness of the symptoms based on the most frequently co-occurring symptoms for different sizes of symptom sets. These results were validated by assessing the statistical significance of the quantitative measures through comparison with random networks of the same size and distribution.

RESULTS

The cancer symptoms tended to co-occur in a nested structure, where there was a small set of symptoms that co-occurred in many patients, and progressively larger sets of symptoms that co-occurred among a few patients.

CONCLUSIONS

These results suggest that cancer symptoms co-occur in a nested pattern as opposed to distinct clusters, thereby demonstrating the value of exploratory network analyses to reveal complex relationships between patients and symptoms. The research also extends methods for exploring symptom co-occurrence, including methods for quantifying the degree of symptom overlap and for examining nested co-occurrence in co-occurrence data. Finally, the analysis also suggested implications for the design of systems that assist in symptom assessment and management. The main limitation of the study was that only one dataset was considered, and future studies should attempt to replicate the results in new data.

Results of intraarterial cisplatin and hyperfractionated radiotherapy in locally advanced cancer of the oropharynx and oral cavity

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Background: Intraarterial cisplatin and hyperfractionated radiation (HYPERADPLAT) is an accepted therapy for Stage III and IV head and neck cancer. We present long-term follow-up of patients with OP and OC cancer treated with HYPERADPLAT at a single institution. Methods: 44 patients with Stage III-IV squamous cell carcinomas of the OP or OC were treated with the HYPERRADPLAT regimen consisting of external beam radiotherapy (76.8–81.6 Gy) delivered in 1.2 Gy BID fractions with intraarterial cisplatin (150 mg/m2) administered when patients had reached 60 Gy. Tumor response, disease free survival (DFS), overall survival (OS), and toxicity were assessed for all patients according to NCI CCT criteria. Results: Of 44 patients, 21 had tumors of the base of tongue, 14-tonsil, 4-floor of mouth, and 5-other. Eighty eight percent of patients had T4 tumors and 7% had T3 tumors. Complete tumor response was observed in 86% of patients and 14% had a partial response. Lymph node metastases were present in 84% of patients with 78% of node positive patients having a complete nodal response and 19% with a partial response to treatment. Three-year DFS was 55% and OS was 45%. Locoregional recurrence was noted in 30% of patients and 16% had distant failure. Overall recurrence was noted in 47% of patients with a median time to recurrence of 8 months (range 4–55 months). Median weight loss during treatment was 9% of initial body weight and 28 patients required a feeding tube within 6 months of starting treatment. Grade 3 mucositis was noted in 68% of patients and 3 patients developed Grade 4 toxicity (2 mucosal, 1 hematologic). Conclusions: HYPERRADPLAT results in excellent tumor control that is well tolerated with minimal Grade 4 toxicity in patients with advanced poor prognosis cancers of the OP and OC. These results compare favorably with historically reported control rates and response for patients with a significantly high percentage of T4 tumors of the oropharynx and oral cavity.

No significant financial relationships to disclose.

Results of reduction of treatment intensity based on response to a novel induction therapy in stage III and IV head and neck cancer

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Background: Concurrent cisplatinum based chemotherapy and qd radiotherapy (RT) to 70 Gy is standard therapy for stage III-IV head and neck (H/N) SCCA. Presented is a prospective IRB approved study tailoring the definitive therapy based on response to induction therapy. Methods: 25 patients with Stage III-IV H/N SCCA were treated with 2 cycles of induction therapy every 21 days comprised of carboplatin (AUC 6 day 1), paclitaxel (75 mg/m2 days 1, 8, and 15), and low dose RT (0.5 Gy BID days 1, 2, 8, and 15) for chemosensitization. The response rates of this mode of induction therapy have been presented previously (ASCO 2005 #3184). Patients with complete response (CR) to induction were treated with reduced dose RT at the primary site (reduced from 70 to 60–66 Gy) and 2 cycles of IV cisplatin (100 mg/m2) instead of 3. Those with partial response (PR) or stable disease (SD) were treated with surgery and adjuvant therapy or with altered fractionation regimens. The impact of dose reduction on survival (OS and DFS), failure patterns, compliance and toxicity (according to NCI CTCAE) were used as end points for the study. Results: Patients included 9 with tonsil, 5-L, 3-HP, 3-OC, and 5-BOT. There were 4-T1,9-T2,9-T3,and 3-T4 tumors. The nodal involvement was N0–5, N1–3, N2–13, N3–4. Patients presented with Stage III (28%), IVA (52%), and IVB (20%). Sixty percent had a CR, 32% had a PR, and 8% had SD after induction therapy. Two patients with CR were non-compliant after induction therapy and not further evaluated. With a median FU of 20.5 months (range 11–36 mo) the OS and DFS is 100% (13/13) in the dose reduced group (CR) and 60% (6/10) in the PR/SD treated with more aggressive regimens. The incidence of distant failure is 40% (4/10) in the PR vs 0% (0/13) in the CR. No patients in the dose reduced group required feeding tubes; however 30% (3/10) were required in patients with PR. Compliance with chemotherapy was 79% (10/13) in the CR vs 80% (8/10) in the PR. Conclusions: Our early results show that the patients showing a CR to induction chemotherapy are a favorable group of patients and they may be treated with reduced treatment intensity. This report provides strong evidence that RT dose deescalation for head and neck cancers may be feasible following assessment after induction therapy.

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Influence of surgical and treatment choices on the cost of breast cancer care

We obtained medical claim files covering a period of 1 year prior to breast cancer diagnosis and the year following diagnosis for 204 women and estimated the cost of their treatment. We used log-linear regression controlling for age, comorbidity, physical functioning, and disease stage. To retransform the mean costs, we estimated separate smearing factors for surgical and adjuvant care types. The adjusted mean costs for breast cancer care ranged from $16,226 to $39,305 depending on the treatment provided with mastectomy being the least expensive option. Breast-conserving surgery (BCS) was more expensive because most women have multiple surgeries after the initial BCS and require adjuvant care. If the first surgery was a mastectomy, medical care use tends to return to precancer spending levels within a few months. Over one-half of the women in this study had multiple surgeries following diagnosis, leading to substantial costs and unknown morbidity.

Observation interval for evaluating the costs of surgical interventions for older women with a new diagnosis of breast cancer

OBJECTIVE

To estimate the episodic costs of surgical treatments for breast cancer.

METHODS

The surgical treatment period as the 6 weeks following diagnosis is defined. Using a sample of 205 women aged 65 and older and their Medicare claim files, the cost of treatment is estimated and the progression from first to subsequent surgical procedures during the 6-week interval is demonstrated with a decision tree. Two equations are then estimated: the probability of mastectomy versus breast conserving surgery (BCS) as first surgery using Probit regression and the log of total charges using a generalized linear regression model.

RESULTS

It was found that only stage predicts the probability of mastectomy versus BCS and that 54% of women receiving BCS undergo a second surgery. Once all treatments in the initial surgical period are accounted, the difference between the adjusted cost of mastectomy alone and BCS followed by a second surgery was not statistically significant. Only a successful first BCS is statistically significantly (P <0.05) less costly than a mastectomy alone ($4,955 vs. $9,049).

CONCLUSIONS

By defining a 6-week surgical treatment episode it is shown that BCS followed by subsequent surgeries is the more costly option for initial treatment. Given the high prevalence of second surgeries, previous work may have underestimated the costs of surgical interventions for breast cancer.

Physical functioning of elderly cancer patients prior to diagnosis and following initial treatment

BACKGROUND AND OBJECTIVES

Using an instrument to measure physical functioning that was normed to the U.S. population, data were obtained from patients with a new diagnosis of breast, colon, lung, and prostate cancer. Two questions were addressed: (a) after controlling for age, and number of comorbid conditions, do site and stage of cancer predict functional limitations prior to diagnosis; (b) using age adjusted national norms on physical functioning, how well do age, number of comorbid conditions, stage, treatment and cluster of symptoms (pain, fatigue, and insomnia) explain changes in physical function between 3 months prior to and 8 weeks following diagnosis?

METHODS

Patients 65 years of age and older were accrued from 24 community oncology settings. Consenting patients were interviewed within 8 weeks of initial treatment. The SF-36 was used to measure physical functioning. Comorbidity and symptom experience were assessed through patient report and site and stage of cancer from record audits.

RESULTS

Prior to diagnosis of cancer, patients were comparable in physical functioning to the U.S. population aged 55-64, a full decade younger than the sample of cancer patients. Site and stage of disease did not account for variations in physical functioning prior to diagnosis. Compared against national norms, patients with more extensive treatments (surgery plus adjuvant therapy) reported greater loss in functioning. Pain, fatigue, and insomnia had a consistent and significant effect on losses in functioning unrelated to patients' treatments or their comorbid conditions.

CONCLUSIONS

Site and stage of cancer prior to diagnosis do not affect functioning. Older cancer patients report higher functioning than their counterparts in the U.S. population. Changes in functioning following diagnosis varied by cancer site. Treatments were related to loss in functioning, but comorbidity was not. Pain, fatigue, and insomnia were significant and independent predictors of change in patient functioning. This underscores the importance of interventions to manage symptoms early in the course of treatment for individuals.