Sleep disruption among cancer patients following autologous hematopoietic cell transplantation

Assessing sleep in primary brain tumor patients using smart wearables and patient-reported data: Feasibility and interim analysis of an observational study

Background

Sleep-wake disturbances are common and disabling in primary brain tumor (PBT) patients but studies exploring longitudinal data are limited. This study investigates the feasibility and relationship between longitudinal patient-reported outcomes (PROs) and physiologic data collected via smart wearables.

Methods

Fifty-four PBT patients ≥ 18 years wore Fitbit smart-wearable devices for 4 weeks, which captured physiologic sleep measures (eg, total sleep time, wake after sleep onset [WASO]). They completed PROs (sleep hygiene index, PROMIS sleep-related impairment [SRI] and Sleep Disturbance [SD], Morningness-Eveningness Questionnaire [MEQ]) at baseline and 4 weeks. Smart wearable use feasibility (enrollment/attrition, data missingness), clinical characteristics, test consistency, PROs severity, and relationships between PROs and physiologic sleep measures were assessed.

Results

The majority (72%) wore their Fitbit for the entire study duration with 89% missing < 3 days, no participant withdrawals, and 100% PRO completion. PROMIS SRI/SD and MEQ were all consistent/reliable (Cronbach's alpha 0.74-0.92). Chronotype breakdown showed 39% morning, 56% intermediate, and only 6% evening types. Moderate-severe SD and SRI were reported in 13% and 17% at baseline, and with significant improvement in SD at 4 weeks (P = .014). Fitbit-recorded measures showed a correlation at week 4 between WASO and SD (r = 0.35, P = .009) but not with SRI (r = 0.24, P = .08).

Conclusions

Collecting sleep data with Fitbits is feasible, PROs are consistent/reliable, > 10% of participants had SD and SRI that improved with smart wearable use, and SD was associated with WASO. The skewed chronotype distribution, risk and impact of sleep fragmentation mechanisms warrant further investigation.

Trial Registration

NCT04 669 574.

The level of fatigue, insomnia, depression, anxiety, stress, and the relationship between these symptoms following allogeneic hematopoietic stem cell transplantation: a cross-sectional study

PURPOSE

This study investigated the incidence of fatigue, insomnia, depression, anxiety, and stress symptoms in patients after allogeneic hematopoietic stem cell transplantation (AHSCT), as well as explored potential relationships among these symptoms.

METHODS

A total of 126 patients who had undergone transplantation at a university hospital at least one month prior to the study's commencement were included. The study was conducted as a cross-sectional and relational research, and data were collected using the "Personal Information Form," "Brief Fatigue Inventory," "Insomnia Severity Index," and "Depression Anxiety Stress Scale." Statistical analyses included descriptive statistics, parametric and nonparametric tests, and correlation analyses using the Spearman Correlation Coefficient. Additionally, mediation analyses were conducted using a Structural Equation Model to explore potential causal relationships among the variables.

RESULTS

The incidence of fatigue was high among patients, with 94% experiencing this symptom following transplantation. Additionally, 52% had anxiety, 47% had insomnia, 47% had depression, and 34% had stress. Moderate relationships were observed between these symptoms. Regression analysis revealed that one-point increase in fatigue was associated with increases in stress 1.065 points, depression 0.937 points, anxiety 0.956 points, and insomnia 0.138 points (p<0.001). Similarly, one-point increase in insomnia was associated with increases in fatigue 3.342 points, stress 0.972 points, depression 0.885 points, and anxiety 0.816 points (p<0.001).

CONCLUSION

After AHSCT, fatigue was the most frequent symptom experienced by patients, followed by insomnia, depression, anxiety, and stress. There was a relationship between these symptoms. Additionally, evidence suggested that insomnia was more strongly associated with fatigue compared to the other symptoms.

Sleep-wake Disturbance following Allogeneic Hematopoietic Stem Cell Transplantation: Trajectory and Correlates.. [DOI: 10.21203/rs.3.rs-2055018/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Adults undergoing allogeneic hematopoietic stem-cell transplant (HSCT) experience progressive physical and psychosocial distress in early stages post-HSCT, including sleep-wake disturbance (SWD), psychological distress, and fatigue. We conducted a longitudinal feasibility study to determine severity/trajectory of SWDs and investigated relationships among actigraphic sleep parameters, sleepiness, insomnia severity, fear of cancer recurrence (FCR), anxiety, depression, and fatigue at 100 (T1), 150 (T2), and 180 days (T3) post-HSCT. Eight adults enrolled. Median total sleep time (TST) at T1–T3 days was adequate (7.24, 7.17, and 7.09 hours), but sleep efficiency (SE) was suboptimal (78.9%, 78.5%, 83.67%). Median Epworth Sleepiness Scale (ESS) and Insomnia Severity Index (ISI) scores indicated minimal drowsiness and subclinical insomnia at T1–T3. Median FCR Inventory (FCRI) scores indicate diminishing FCR over time. Median scores across time for anxiety (48.05, 50.2, and 44.1) and depression (44.9, 41, and 41) suggest moderate–mild distress with slight fluctuations. Surprisingly, fatigue scores increased from T1–T3 (46, 50.9, and 52.1). Increases in ISI and FCRI scores were associated with modest increases in anxiety. Findings suggest the need to evaluate and address sleep, psychological distress, and fatigue in HSCT recipients. Larger studies to confirm prevalence of SWD and association with psychological factors are warranted.

Biobehavioral Implications of Covid-19 for Transplantation and Cellular Therapy Recipients

A growing body of literature has emphasized the importance of biobehavioral processes - defined as the interaction of behavior, psychology, socioenvironmental factors, and biological processes - for clinical outcomes among transplantation and cellular therapy (TCT) patients. TCT recipients are especially vulnerable to distress associated with pandemic conditions and represent a notably immunocompromised group at greater risk for SARS-CoV-2 infection with substantially worse outcomes. The summation of both the immunologic and psychologic vulnerability of TCT patients renders them particularly susceptible to adverse biobehavioral sequelae associated with the Covid-19 pandemic. Stress and adverse psychosocial factors alter neural and endocrine pathways through sympathetic nervous system and hypothalamic-pituitary-adrenal axis signaling that ultimately affect gene regulation in immune cells. Reciprocally, global inflammation and immune dysregulation related to TCT contribute to dysregulation of neuroendocrine and central nervous system function, resulting in the symptom profile of depression, fatigue, sleep disturbance, and cognitive dysfunction. In this article, we draw upon literature on immunology, psychology, neuroscience, hematology and oncology, Covid-19 pathophysiology, and TCT processes to discuss how they may intersect to influence TCT outcomes, with the goal of providing an overview of the significance of biobehavioral factors in understanding the relationship between Covid-19 and TCT, now and for the future. We discuss the roles of depression, anxiety, fatigue, sleep, social isolation and loneliness, and neurocognitive impairment, as well as specific implications for sub-populations of interest, including pediatrics, caregivers, and TCT donors. Finally, we address protective psychological processes that may optimize biobehavioral outcomes affected by Covid-19.

What is the prevalence of fear of cancer recurrence in cancer survivors and patients? A systematic review and individual participant data meta-analysis

OBJECTIVE

Care for fear of cancer recurrence (FCR) is considered the most common unmet need among cancer survivors. Yet the prevalence of FCR and predisposing factors remain inconclusive. To support targeted care, we provide a comprehensive overview of the prevalence and severity of FCR among cancer survivors and patients, as measured using the short form of the validated Fear of Cancer Recurrence Inventory (FCRI-SF). We also report on associations between FCR and clinical and demographic characteristics.

METHODS

This is a systematic review and individual participant data (IPD) meta-analysis on the prevalence of FCR. In the review, we included all studies that used the FCRI-SF with adult (≥18 years) cancer survivors and patients. Date of search: 7 February 2020. Risk of bias was assessed using the Joanna Briggs Institute critical appraisal tool.

RESULTS

IPD were requested from 87 unique studies and provided for 46 studies comprising 11,226 participants from 13 countries. 9311 respondents were included for the main analyses. On the FCRI-SF (range 0-36), 58.8% of respondents scored ≥13, 45.1% scored ≥16 and 19.2% scored ≥22. FCR decreased with age and women reported more FCR than men. FCR was found across cancer types and continents and for all time periods since cancer diagnosis.

CONCLUSIONS

FCR affects a considerable number of cancer survivors and patients. It is therefore important that healthcare providers discuss this issue with their patients and provide treatment when needed. Further research is needed to investigate how best to prevent and treat FCR and to identify other factors associated with FCR. The protocol was prospectively registered (PROSPERO CRD42020142185).

Long-term patient-reported neurocognitive outcomes in adult survivors of hematopoietic cell transplant

Long-term adult HCT survivors reported average cognitive quality of life compared with the general population.

Survivors with hearing issues and sleep impairments were more likely to report lower quality of life and impaired neurocognitive function.

Survivors of hematopoietic cell transplant (HCT) are at risk for neurocognitive impairments, which can negatively affect quality of life. Given limited studies, we aimed to describe the neurocognitive outcomes in a cohort of long-term adult HCT survivors. Eligible survivors (age ≥21 years at HCT and alive ≥2 years following HCT) completed a 60-question survey of neurocognitive function and quality of life, which included the Neuro-Quality of Life Cognitive Function Short Form (Neuro-QoL) and the Childhood Cancer Survivor Study Neurocognitive Questionnaire (NCQ). Analyses of risk factors included univariate comparisons and multivariable logistic regression. Survivors (n = 1861, 47.7% female, 65.6% allogeneic HCT) were surveyed at a median age of 64.2 years (interquartile range [IQR], 56.8-70.5) and a median 12.0 years (IQR, 6.0-21.0) from HCT. Survivors reported average Neuro-QoL scores (50.0 allogeneic; 49.2 autologous survivors) compared with an expected mean of 50 in the general population. On the NCQ, 17.4% to 31.2% of survivors reported impairments (Z-score >1.28) in task efficiency, memory, emotional regulation, or organization, compared with an expected 10% in the general population (all P < .01). In multivariable regression analyses, impaired Neuro-QoL (T-score <40) was independently associated with hearing issues (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.46-3.10) and sleep impairment (OR, 4.41; 95% CI, 2.80-6.94) among allogeneic survivors, with comparable associations in autologous survivors. Overall, long-term adult HCT survivors reported average cognitive quality of life compared with the general population. Subsets of survivors with hearing issues and sleep impairments were more likely to report lower quality of life and impaired neurocognitive function, which may facilitate targeted monitoring or interventions following HCT.

Insomnia in Post-Hematopoietic Stem-Cell Transplant Patients in Jordan: Prevalence and Associated Factors

Background and Objective Insomnia is a common symptom that is experienced by the patients post hematopoietic stem cell transplant that interfere with recovery outcomes and patients’ quality of life. Little is known about insomnia among post hematopoietic stem cell transplant in Jordan and in other Arab countries. The purpose of the current study was to identify the levels of insomnia and the related factors in post hematopoietic stem cell transplant.Methods A descriptive cross-sectional correlational design was used to guide this study. Data was collected from 163 patients by the Arabic version of the Insomnia Severity Index (ISI).Results The participant’s average ISI was 14.06 ± 7.71 indicating sub-threshold insomnia. Regarding the insomnia levels, 23.9% of the participants reported no insomnia, 27.6% had subthreshold insomnia, 31.3% had moderate clinical insomnia, and 17.2% had severe clinical insomnia. A significant difference in insomnia levels in some related factors was reported including the higher educated patients (t = 2.40, p = 0.018), patients who received allogeneic transplants (t = -2.932, p = 0.004), and patients within a 30 days’ post-transplant (F (160, 2) = 61.03, p < 0.001).Conclusions In conclusion, the overall prevalence of insomnia among post HSCT patients was 48.5% (n = 79) that suggested clinical insomnia, and it was affected by several clinical variables. Further studies are needed to provide appropriate interventions to decrease insomnia levels among patients.

Clinical characterization and cytokine profile of fatigue in hematologic malignancy patients with chronic graft-versus-host disease

Limited information is available regarding clinical and biological properties of fatigue in patients with chronic graft-versus-host disease (cGvHD). Patients with moderate-to-severe cGvHD per NIH criteria were enrolled on a cross-sectional study and categorized as "fatigued" if SF-36 vitality score was <40. Clinical and laboratory parameters of fatigued (n = 109) and nonfatigued patients (n = 72) were compared. In univariate analysis, walk velocity, NIH joint-fascia score, human activity profile, and SF-36 physical and mental health self-report scales were correlates of fatigue. No cGvHD biomarkers were associated with fatigue. NIH joint score, Lee sleep and depression questions, and PG-SGA activities and function score jointly predicted fatigue. Though higher rates of depression and insomnia were reported in the fatigued group, antidepressant or sleep aid use did not differ between groups. Survival ratio was not significantly different by fatigue status. Pathophysiology of fatigue in patients with cGvHD is complex and may involve mechanisms unrelated to disease activity. Patients with cGvHD experiencing fatigue had higher rates of untreated depression and insomnia, highlighting the need to focus clinical management of these conditions to improve health-related quality of life.

Sleep Disruption, Fatigue, and Depression as Predictors of 6-Year Clinical Outcomes Following Allogeneic Hematopoietic Cell Transplantation

BACKGROUND

Allogeneic hematopoietic cell transplantation (HCT) is a widely used treatment for hematologic cancers, with survival rates ranging from 25% to 78%. Known risk factors for chronic graft-versus-host disease (cGVHD), a serious and common long-term complication, disease relapse, and mortality following HCT have been identified, but much of the variability in HCT outcomes is unexplained. Biobehavioral symptoms including depression, sleep disruption, and fatigue are some of the most prevalent and distressing for patients; yet research on biobehavioral risk factors for HCT outcomes is limited. This study evaluated patient-reported depression, sleep disruption, and fatigue as risk factors for cGVHD, disease relapse, and mortality.

METHODS

Adults receiving allogeneic HCT for a hematologic malignancy (N = 241) completed self-report measures of depression symptoms, sleep quality, and fatigue (severity, interference) pre-HCT and 100 days post-HCT. Clinical outcomes were monitored for up to 6 years.

RESULTS

Cox proportional hazard models (2-tailed) adjusting for patient demographic and medical characteristics revealed that high pre-HCT sleep disruption (Pittsburgh Sleep Quality Index >9; hazard ratio [HR] = 2.74, 95% confidence interval [CI] = 1.27 to 5.92) and greater post-HCT fatigue interference (HR = 1.32, 95% CI = 1.05 to 1.66) uniquely predicted increased risk of mortality. Moderate pre-HCT sleep disruption (Pittsburgh Sleep Quality Index 6-9) predicted increased risk of relapse (HR = 1.99, 95% CI = 1.02 to 3.87). Biobehavioral symptoms did not predict cGVHD incidence.

CONCLUSIONS

Biobehavioral symptoms, particularly sleep disruption and fatigue interference, predicted an increased risk for 6-year relapse and mortality after HCT. Because these symptoms are amenable to treatment, they offer specific targets for intervention to improve HCT outcomes.

Contribution of Sleep Disruption and Sedentary Behavior to Fatigue in Survivors of Allogeneic Hematopoietic Cell Transplant

BACKGROUND

Fatigue is a prominent quality of life concern among recipients of hematopoietic cell transplantation (HCT).

PURPOSE

The present study investigated whether objectively measured sleep efficiency and sedentary behavior are related to greater reports of fatigue.

METHODS

Eighty-two allogeneic HCT recipients who were 1-5 years post-transplant and returning for a follow-up visit participated (age M = 56, 52% female, 56% leukemia). They wore an actigraph assessing sleep efficiency and sedentary behavior for one week and completed an electronic log assessing fatigue each evening during the same period.

RESULTS

Twenty-six percent of patients reported clinically meaningful fatigue. On average, fatigue was mild (M = 2.5 on 0-10 scale, SD = 2.0), sleep was disturbed (sleep efficiency M = 78.9%, SD = 8.9), and patients spent the majority of time in sedentary (M = 55.4%, SD = 10.2) or light (M = 35.9%, SD = 8.6) activity. Multilevel model analysis of between-person differences indicated that patients who experienced less efficient sleep the previous evening provided greater evening reports of average fatigue, b = -0.06, 95% CI (-0.11, -0.01). Similarly, within-person analyses indicated that when patients experienced less efficient sleep the previous evening or were more sedentary as compared to their average, they provided greater evening reports of average fatigue, b = -0.02, 95% CI (-0.05, -0.004); b = 4.46, 95% CI (1.95, 6.97), respectively.

CONCLUSIONS

Findings demonstrate that poor sleep and daily sedentary behavior are related to evening reports of fatigue and should be considered modifiable targets for intervention.

Biobehavioral Research and Hematopoietic Stem Cell Transplantation: Expert Review from the Biobehavioral Research Special Interest Group of the American Society for Transplantation and Cellular Therapy

Hematopoietic stem cell transplantation (HCT) is a potentially curative treatment for many hematologic conditions. Despite advances in conditioning and supportive measures, however, there remain significant comorbidities that threaten survivorship. Adverse effects of stress-related biobehavioral processes-defined here as the interactions of behavioral, psychological, and socioenvironmental factors with biology-impact immune recovery and function and are particularly salient in the HCT context, given the importance of immune reconstitution for improved survivorship. However, biobehavioral processes have been underinvestigated in this vulnerable group compared with other cancer populations. Here the Biobehavioral Research Special Interest Group (SIG) of the American Society for Transplantation and Cellular Therapy provides an expert review to inform research directions explicating the biological correlates of behavioral symptoms and evaluate the impact of these on HCT outcomes. The goal of this expert review is to provide a foundation for advancing science that effectively integrates behavioral and biological processes to optimize quality of life and improve clinical outcomes for HCT recipients.

Spotlight on the Fear of Cancer Recurrence Inventory (FCRI)

Fear of cancer recurrence (FCR) is a pervasive concern for people living with cancer. The rapidly expanding FCR literature has been weakened somewhat by use of miscellaneous FCR measures of varying quality. The Fear of Cancer Recurrence Inventory (FCRI) has been widely used in observational and intervention studies and the FCRI severity subscale, also known as the FCRI-Short Form (FCRI-SF), is often used to identify potential cases of clinically significant FCR. Given the FCRI's increasing use in research and clinical practice, we aimed to provide an overview, critique, and suggested improvements of the FCRI. Studies citing the original FCRI validation paper were identified and synthesised using narrative and meta-analytic methods. The 42-item FCRI has demonstrated a reasonably robust 7-factor structure across evaluations in multiple languages, although certain subscales (eg, Coping) demonstrate sub-optimal reliability. Confirmation of the cross-cultural equivalence of several FCRI translations is needed. Meta-analysis of FCRI-SF scores revealed a combined weighted mean score of 15.7/36, a little above the lowest proposed cut-off score (≥13) for clinical FCR. Depending on the FCRI-SF cut-off used, between 30.0% and 53.9% of the cancer population (ie, patients and survivors) appear to experience sub-clinical or clinical FCR. Higher FCRI scores were associated with younger age and female gender, pain/physical symptoms and psychological morbidity, consistent with the FCR literature generally. Issues regarding the application and interpretation of the FCRI remain. Whether the FCRI is well suited to assessing fear of progression as well as recurrence is unclear, the meaningfulness of the FCRI total score is debatable, and the use of the FCRI-SF to screen for clinical FCR is problematic, as items do not reflect established characteristics of clinical FCR. Refinement of the FCRI is needed for it to remain a key FCR assessment tool in future research and clinical practice.

Free of malignancy but not of fears: A closer look at Damocles syndrome in survivors of hematologic malignancies

Fear of cancer recurrence (FoR) is an important yet underestimated long term sequela that many cancer survivors suffer from. The continuous state of uncertainty the survivors might go through can lead to a serious impact on their quality of life (QoL), which is collectively referred to as Damocles syndrome. Given the increasing numbers of cancer survivors, it is crucial to understand the different psychological issues that face them, including Damocles syndrome. Herein, we review the current literature of Damocles syndrome specifically in hematologic cancer survivors. Although with inconsistent terms, current literature demonstrates the impact and the prevalence of Damocles syndrome on QoL of survivors of leukemia, lymphoma, and hematopoietic cell transplant. Interventional studies are very limited in this area. Moreover, hematologic malignancy survivors can also meet the diagnostic criteria of other psychiatric diseases, including depression, anxiety, and post-traumatic stress disorder, wherein they should be managed accordingly. It is important to increase the awareness about Damocles syndrome and screen patients for it and other related psychological disorders. Additionally, this review has shown the need for standardization of Damocles syndrome definitions. Finally, the lack of interventional studies that target survivors' psychosocial challenges calls for prospective research to better address this rising problem.

Circadian Rhythmicity as a Predictor of Quality of Life in Allogeneic Hematopoietic Cell Transplant Patients

CONTEXT

Quality of life (QoL) is increasingly recognized as an important outcome of cancer treatment. Previous studies have examined clinical predictors of QoL, but with the increasing prevalence of wearable sensors that monitor sleep and activity patterns, further investigation into whether these behaviors are predictive of post-treatment QoL is now feasible. Among patients receiving aggressive cancer treatment such as hematopoietic cell transplantation (HCT), analysis of circadian rhythms (24-hour patterns of sleep and activity) via wearable sensors is limited.

OBJECTIVE

To evaluate the relationship between overall QoL and circadian rhythms in patients receiving allogeneic HCT.

METHODS

Patients wore an ActiGraph GT3X (Pensacola, FL) activity monitor for at least 72 hours before the initiation of conditioning chemotherapy and transplantation and completed a QoL (Functional Assessment of Cancer Therapy-General [FACT-G]) assessment. QoL assessments were also completed 1, 3, and 6 months after HCT.

RESULTS

Patients (n = 45, M age = 55) were mostly male (66%) with a total FACT-G score of 80.96 (SD = 16.05) before HCT. Mixed models revealed robust cross-sectional associations between overall QoL and multiple circadian rhythmicity parameters, including durations of high physical activity, overall circadian rhythmicity, and earlier starts of daily activity (P's < .01). Recovery of QoL after transplant was predicted by longer pre-transplant durations of high physical activity (P = .04) and earlier evening retirement (P = .04).

CONCLUSION

Our findings suggest that wearable sensor information is a promising method of predicting recovery of QoL after HCT. Additional studies are needed to confirm these findings in a larger sample.