Change in longitudinal trends in sleep quality and duration following breast cancer diagnosis: results from the Women's Health Initiative

A qualitative study of sleep in young breast cancer survivors: "No longer able to sleep through the night"

Sleep disturbance is common among women with breast cancer and is associated with greater symptom distress and poorer outcomes. Yet, for the unique subgroup of young women with breast cancer (YWBC), there is limited information on sleep. To address the gap in our understanding of sleep health in YWBC, we explored their perspective on sleep quality, sleep changes over time, contributing factors, and any strategies used to promote sleep. As part of an explanatory sequential mixed method study, we recruited a sub-sample of 35 YWBC (≤ 50 years of age at the time of diagnosis) from the larger quantitative study phase. These participants were within the first 5 years since diagnosis and completed primary and systemic adjuvant therapy. We conducted virtual semi-structured interviews, transcribed them verbatim, and analyzed data with an interpretive description approach. YWBC experience difficulty falling asleep, waking up at night, and not feeling refreshed in the morning. They attributed interrupted sleep to vasomotor symptoms, anxiety/worry, ruminating thoughts, everyday life stressors, and discomfort. The sleep disturbance was most severe during and immediately after treatment but persisted across the 5 years of survivorship. The participants reported trying pharmacologic and non-pharmacologic strategies to improve the quantity and quality of their sleep. Future research would benefit from longitudinal designs to capture temporal changes in sleep and develop interventions to improve sleep health. Clinically, assessment of sleep health is indicated for YWBC related to the prevalence of disturbed sleep. IMPLICATIONS FOR CANCER SURVIVORS: Early access to sleep assessment and management, ideally before cancer treatment, would be beneficial for young breast cancer survivors. In addition, cancer treatment plans should include physical and psychological symptoms, especially those reported by women in this study: vasomotor symptoms, anxiety and worry, discomfort, and pain.

Sleep disturbance among breast cancer survivors and controls from midlife to early older adulthood: Pink SWAN

PURPOSE

To compare sleep disturbance from 5 years pre- to 5 years post-diagnosis between breast cancer survivors (BCS) and women without cancer over the same period and to identify BCS subgroups exhibiting different sleep trajectories.

METHODS

Analyses included data from 152 BCS and 2163 controls from 20 years of follow-up in the longitudinal Study of Women's Health Across the Nation (SWAN), a multi-racial/ethnic cohort study. SWAN participants were assessed approximately annually from 1995 to 2015 using a standardized protocol. Pink SWAN focused on women who reported no cancer at SWAN enrollment and developed incident breast cancer after enrollment or did not develop breast cancer. Nonparametric locally weighted scatterplot smoothing plots and linear mixed models were used to compare the prevalence of the most frequently reported sleep problem, frequently waking several times a night (a sleep maintenance problem) during the previous 2 weeks, between BCS and controls in the 5 years pre- to 5 years post-diagnosis. We characterized heterogeneity among BCS on this sleep problem using group-based trajectories and examined pre-diagnosis variables as predictors of group membership.

RESULTS

No differences were found between BCS and controls in prevalence of frequent nighttime awakenings either before or after diagnosis. Among BCS, three trajectory groups were identified. Thirty-seven percent of BCS had consistently low prevalence of waking several times per night, 30% had high prevalence, and 33% had increasing prevalence which started 2 years pre-diagnosis. Prevalence of pre-diagnosis vasomotor symptoms, anxiety, depressive symptoms, and smoking differed among these groups.

CONCLUSION

Among mid-aged women diagnosed with breast cancer, this diagnosis did not trigger/amplify a sleep maintenance problem. The majority of BCS had similar levels of this sleep problem from pre- to post-diagnosis.

IMPLICATIONS FOR CANCER SURVIVORS

Although sleep maintenance problems were not amplified by a cancer diagnosis, a subset of BCS may have sleep issues that should be monitored and treated, as indicated.

Global prevalence of sleep disturbances among breast cancer survivors: A systematic review with meta-analysis

Breast cancer is a common cancer in which patients are highly susceptible to different sleep disturbances. However, current evidence lacked consistency in methodologies in investigating the prevalence of sleep disturbances among breast cancer survivors. The review aims to (1) investigate the global prevalence of sleep disturbances among breast cancer survivors; and (2) investigate the factors influencing the prevalence estimates. A comprehensive search was conducted in 8 databases using a 3-step approach, up to January 2022. The Newcastle-Ottawa Scale and Cochrane risk of bias tool were used to evaluate the quality of individual studies. Meta-analysis, meta-regression, and subgroup analysis were performed using R software. Certainty of evidence was assessed using Grading of Recommendations, Assessment, Development, and Evaluations criteria. A total of 51 studies were selected involving 28,036 breast cancer survivors across 17 countries. The global prevalence of poor sleep quality was 62%, different severities of insomnia were 3%-32%, and excessive daytime sleepiness was 24%. Subgroup analyses showed that a significantly higher prevalence of poor sleep quality was found in breast cancer survivors during treatment compared with pre- or post-treatment. No significant covariates were found in a series of meta-regression analyses. The majority (73.5%) of individual studies were high quality but the certainty of the evidence was low or very low according to Grading of Recommendations, Assessment, Development, and Evaluations criteria. More than half of breast cancer survivors have sleep disturbances, so developing a strategic intervention is warranted. Given the low or very low certainty of the evidence, a robust design for large-scale research is crucial in the future.

Sleep Deficiency: A Symptoms Perspective: Exemplars from Chronic Heart Failure, Inflammatory Bowel Disease, and Breast Cancer

Sleep deficiency is associated with disabling daytime symptoms, including excessive daytime sleepiness (EDS) and fatigue. The purpose of this article is to discuss the contributions of sleep deficiency and sleep disorders to fatigue and EDS among people with chronic conditions. We use exemplars from the literature on chronic heart failure, inflammatory bowel disease, and breast cancer to (1) describe the prevalence of fatigue and EDS and their consequences; (2) examine the evidence for the contributions of sleep deficiency and sleep disorders to these symptoms; and (3) recommend implications for future research and practice.

Sleep macro- and microstructure in breast cancer survivors

Complaints of sleep disturbance are prevalent among breast cancer (BC) patients and are predictors of quality of life. Still, electrophysiological measures of sleep are missing in patients, which prevents from understanding the pathophysiological consequences of cancer and its past treatments. Using polysomnography, sleep can be investigated in terms of macro- (e.g. awakenings, sleep stages) and micro- (i.e. cortical activity) structure. We aimed to characterize sleep complaints, and macro- and microstructure in 33 BC survivors untreated by chemotherapy and that had finished radiotherapy since at least 6 months (i.e. out of the acute effects of radiotherapy) compared to 21 healthy controls (HC). Compared to HC, BC patients had a larger number of awakenings (p = 0.008); and lower Delta power (p < 0.001), related to sleep deepening and homeostasis; greater both Alpha (p = 0.002) and Beta power (p < 0.001), related to arousal during deep sleep; and lower Theta power (p = 0.004), related to emotion regulation during dream sleep. Here we show that patients have increased cortical activity related to arousal and lower activity related to sleep homeostasis compared to controls. These results give additional insights in sleep pathophysiology of BC survivors and suggest sleep homeostasis disruption in non-advanced stages of BC.

Sleep Quality and Cancer-Related Fatigue in Patients with Cancer

Introduction: Sleep problems and fatigue are common symptoms reported by cancer patients. In this study, the researchers used a specialized tool to measure fatigue in cancer patients and its relationship with sleep quality in Yazd, Iran.

Methods: This descriptive correlational study included 149 cancer patients (age range: over 18 years) referred to Shahid Sadoughi Hospital in Yazd, Iran. Data were collected by the Pittsburgh Sleep Quality Index (PSQI) and Cancer-Related Fatigue Questionnaire. A PSQI score of ≥5 indicated a poor sleep. Data were analyzed using SPSS Statistics for Windows, version 13.0 (SPSS Inc., Chicago, IL, USA), Pearson’s correlation, t test, analysis of variance (ANOVA), and linear regression.

Results: The mean (SD) PSQI score of patients was 13 (4.85) out of 21. About 69.3% of patients had a poor sleep quality. While the mean (SD) of sleep duration was 5.57 (0.54) hours, it was 69.44 (46.58) minutes for sleep latency. Also, with increasing the mean of sleep quality, the mean of fatigue significantly increased (P < 0.001, R=0.63).

Conclusion: According to the results, there was a relationship between the sleep quality and fatigue in cancer patients, so that patients with better sleep quality had less fatigue.

Factors associated with sleep disturbances in women undergoing treatment for early-stage breast cancer

PURPOSE

The purpose of this study was to examine factors associated with sleep disturbance in women receiving adjuvant therapy for breast cancer.

METHODS

This study employed a cross-sectional design using data collected at 3 months post-surgery from an ongoing longitudinal parent study. Participant data were divided into adjuvant treatment groups (chemotherapy, radiation, and aromatase inhibitors) and no adjuvant treatment groups. Symptoms were measured using patient self-report measures. Analysis of variance was used to assess between adjuvant treatment group differences in sleep disturbance. Regression analysis was performed to assess the relationship between sleep disturbance and other symptoms within adjuvant treatment groups.

RESULTS

The sample included 156 women diagnosed with early-stage breast cancer. There were significant differences in levels of reported sleep disturbance between treatment groups (p = 0.049), with significantly higher levels of sleep disturbances in those receiving radiation compared to those receiving no adjuvant treatment (p = 0.038) and in those receiving chemotherapy and those receiving no adjuvant treatment (p = 0.027). Increased sleep disturbance was found to be a significant predictor for increased pain severity, nausea severity, anxiety, depressive symptoms, fatigue, decreased physical function, and decreased ability to participate in social roles and activities. Co-occurring symptoms with sleep disturbance differed between adjuvant treatment groups. Sleep disturbance was also associated with younger age (p = 0.008).

CONCLUSIONS

Patients undergoing chemotherapy or radiation for breast cancer report higher levels of sleep disturbance than those not receiving adjuvant therapy. Sleep disturbance is associated with other symptoms experienced by patients with cancer and thus requires continual assessment and future research into effective interventions.

The mindfulness-based stress reduction program for improving sleep quality in cancer survivors: A systematic review and meta-analysis

INTRODUCTION

This study aims to evaluate the efficacy and effectiveness of a mindfulness-based stress reduction (MBSR) program in improving sleep in cancer survivors.

METHODS

Four electronic databases (Cochrane Library, EMBASE, PubMed, and PsycARTICLES) were searched for randomized controlled trials evaluating the effects of MBSR on the sleep of cancer survivors from their inception to May 2020. The primary outcome was sleep quality measured by validated questionnaires such as the Insomnia Severity Index and Pittsburgh Sleep Quality Index. The secondary outcomes were sleep parameters obtained from a sleep diary, polysomnography, and actigraphy. The included studies were critically appraised by the Cochrane risk of bias tool and meta-analyzed.

RESULTS

Ten studies were included, and nine studies were analyzed quantitatively. MBSR significantly improved sleep quality compared to usual care (standardized mean difference -0.29, 95 % confidence interval -0.55 to -0.04, I² = 58 %). However, there were no favorable results with sleep parameters. Compared to active controls, MBSR presented mixed results with sleep quality according to the outcomes and negative results with sleep parameters.

CONCLUSION

This review suggests that MBSR helps cancer survivors improve sleep quality. Our results support the possibility of using MBSR for cancer survivors. However, its efficacy and effectiveness in improving sleep quality and sleep parameters are inconclusive because the number of included studies was few with inconsistent results. Further studies with high methodological quality are required to establish conclusive evidence about the efficacy and effectiveness of MBSR in improving sleep quality and sleep parameters in cancer survivors.

Psychometric properties of the Insomnia Severity Index in cancer survivors

OBJECTIVE

Insomnia is commonly associated with cancer treatment. Cancer treatments increase risk for numerous psychological and medical late effects, thus making cancer survivors psychologically and medically vulnerable. Prior research examined psychometric properties of the Insomnia Severity Index (ISI) with various populations, including the French version of the ISI, with participants undergoing active cancer treatment. However, no prior studies examined insomnia exclusively with cancer survivors, using the English version of the ISI.

METHODS

This study examined internal consistency and factor structure of an English version of the ISI in 100 cancer survivors (M_age  = 51.1; SD = 14.92). This final analytic sample was composed of participants from three different insomnia interventions. Survivors ranged from less than 1 year off treatment (17%) to 21+ years off treatment (6%), with most participants off treatment for 1 to 2 years (24%).

RESULTS

The mean ISI score for the total sample was 16.69 (SD = 4.47), indicating clinical insomnia, with moderate severity. Principal Components Analysis (PCA) indicated two factors (five items loading on Factor I and two items loading on Factor II) and acceptable reliability (α = .73). Item-total correlations ranged from .15 to .63.

CONCLUSIONS

Findings support the reliability of the ISI in cancer survivors. However, its factor structure warrants additional research with larger samples of cancer survivors. Results suggest inconsistency across participant responses and that ISI items may be functioning differently with this unique population of cancer survivors. Findings indicate that sleep maintenance problems are central to the experience of insomnia in our survivor sample.