Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

The Interplay of Chronic Stress and Cancer: Pathophysiology and Implications for Integrated Care

BACKGROUND

Cancer-associated depression is a multifaceted condition that arises from the interplay of biological, psychological, and social factors in individuals diagnosed with cancer. Understanding this condition involves exploring how cancer and its treatments can precipitate depressive symptoms and the mechanisms behind this association. Chronic stress, inflammation, and immunological responses play a crucial role in the development of both cancer and depression. The objective of this review is to describe and synthesize information on the complex interactions between chronic stress, inflammation, immunological responses, and cancer development. Additionally, it aims to review existing evidence regarding mechanisms such as neurotransmitter imbalances, structural brain changes, and genetic predispositions as key contributors to depression in cancer patients.

RECENT FINDINGS

A comprehensive literature search on Cancer-associated Depression was conducted in electronic databases, including APA PsycINFO, Medline, Google Scholar, Embase, PubMed, Scopus, and Web of Science. The research focused on understanding the potential relationship between stress-induced depression and cancer by examining neurochemical, anatomical, immunological, genetic, and psychological changes. The findings revealed a compilation of both quantitative and qualitative studies on depression in cancer patients. Evidence suggested a potential link between cancer-induced stress and depression, with increased levels of proinflammatory cytokines (such as IL-6) and dysregulation of neurotransmitters, including serotonin, contributing to the onset of depression. Furthermore, studies indicated that antidepressants, along with psychological interventions, were effective in managing depression among cancer patients.

CONCLUSION

This narrative review provides insights into the importance of integrating oncology and mental health services to address the psychosocial needs of cancer patients. Future research should focus on the bidirectional interactions between stress and cancer, aiming to improve cancer care by incorporating mental health support. Addressing the mental health aspects of cancer treatment can significantly enhance patient outcomes and overall quality of life.

Sleep quality and physical fitness as modifiable contributors of fatigue in childhood cancer survivors

PURPOSE

Advances in cancer treatment have increased childhood cancer patient's survival rates. However, many childhood cancer survivors (CCS) face long-term effects such as fatigue. This study assessed fatigue in CCS and healthy controls (HCs), its contributors, and associated outcomes.

METHODS

This cross-sectional study included 90 CCS and 55 age and sex-matched HCs. Fatigue was measured using the Pediatric Quality of Life Multidimensional Fatigue Scale, and modifiable contributors included sleep quality (Pittsburgh Sleep Quality Index [PSQI]) and physical fitness (VO2 peak during a treadmill test). Quality of life (QoL) and emotional and cognitive functioning were evaluated using the Pediatric Quality of Life Inventory, Beck Depression Inventory II, Cognitive Failure Questionnaire, and the Impact of Event Scale-Revised. Stepwise linear regressions identified predictors of general, sleep/rest, cognitive, and total fatigue.

RESULTS

General, cognitive, and total fatigue were significantly higher in CCS compared to HCs (44.7% vs. 23%, p < .001; cognitive: 64.7% vs. 29.3%, p < .001; total fatigue: 56.5% vs. 25%, p < .001). Sex, PSQI, PSQI × sex, and PSQI × VO₂ were significant predictors for general fatigue, PSQI and PSQI × VO₂ for cognitive fatigue, and PSQI for sleep/rest and total fatigue. Cognitive and total fatigue correlated most strongly with cognitive and work-related functioning, whereas general and sleep/rest fatigue were more related to psychosocial functioning.

CONCLUSION

Fatigue is highly prevalent among CCS, with distinct factors influencing general, sleep/rest, cognitive, and total fatigue. Female survivors, those with poorer sleep quality and lower physical fitness, are at risk.

IMPLICATIONS FOR CANCER SURVIVORS

This study underscores the need for tailored interventions for each type of fatigue. Improving sleep quality, physical fitness, and psychological well-being may contribute to reducing fatigue and enhancing overall quality of life in CCS.

Comparative efficacy of interventions for insomnia in cancer patients: a systematic review and network meta-analysis

BACKGROUND

Cancer-related insomnia demonstrates twice the prevalence observed in the general population, with significant implications for disease progression. This network meta-analysis systematically compares the therapeutic efficacy of diverse interventions for managing insomnia in oncological populations.

METHODS

We systematically queried four biomedical databases (PubMed, Embase, Medbase, and Web of Science) for eligible studies assessing insomnia interventions in cancer patients. Primary outcomes encompassed standardized metrics: Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), sleep onset latency (SOL), wake after sleep onset (WASO), total sleep time (TST), and sleep efficiency (SE). A frequentist approach with random-effects model was employed for comparative effectiveness analysis.

RESULTS

The analysis incorporated 21 studies with sample sizes ranging from 16 to 255 participants. Comparative evaluation against standard care revealed that both cognitive behavioral therapy for insomnia (CBT-I) (MD = - 3.04, 95%CI[- 4.49,-1.59]) and electroacupuncture (MD = - 3.80, 95%CI[- 6.50,-1.09]) produced clinically meaningful reductions in ISI scores, while CBT-I (MD = 2.71%, 95%CI[0.89,4.53]) and Tai Chi (MD = 5.26%, 95%CI[0.41,10.11]) exhibited statistically significant improvements in sleep efficiency metrics.

CONCLUSIONS

CBT-I emerges as an evidence-based intervention for ameliorating insomnia severity and optimizing sleep efficiency in cancer patients. Complementary modalities including electroacupuncture and Tai Chi present viable alternatives. Methodological limitations necessitate future rigorously designed trials to strengthen clinical recommendations.

Adapting and validating the satisfaction, alertness, timing, efficiency, and duration-breast cancer (SATED-BC) scale for measuring sleep health in Spanish women treated for breast cancer

BACKGROUND

After breast cancer (BC), women may face other severe symptoms such as sleep problems. The use of simple, fast, and reliable scales is necessary in the clinic to improve patient benefits, and sleep is an important aspect to be addressed.

OBJECTIVE

This study was conducted to adapt and validate the Spanish version of the satisfaction, alertness, timing, efficiency, and duration (SATED) scale for measuring sleep health in women who have completed treatment for BC in Spain (SATED-BC).

DESIGN

Cross-sectional study.

METHODS

The adaptation process involved adding a sixth item to the SATED-BC scale: "the impact of symptoms experienced after completing breast cancer treatment on sleep" item was not considered for scoring. The SATED-BC score ranged from 0 (poorest sleep health) to 10 (best sleep health). A validation analysis was performed using the Pittsburgh Sleep Quality Index, the Consensus Sleep Diary, and actigraphy, and the results were compared with those obtained using the SATED-BC scale.

RESULTS

The SATED-BC scale was reliable in terms of its internal consistency (Cronbach's α = 0.70; McDonald's ω = 0.72), showed high intrasubject reliability (r = 0.90), and was shown to be valid for use in women who have completed treatment for breast cancer.

CONCLUSION

The SATED-BC scale is a reliable and valid tool for comprehensively evaluating sleep health in women who have completed treatment for breast cancer.

Comparison of subjectively and objectively measured sleep-wake patterns among patients with primary brain tumors

Background

The sleep diary and wrist-worn actigraphy are widely used to assess sleep disturbances in patients with primary brain tumors (PwPBT) in both clinical and research settings. However, their comparability has not been systematically examined. This study aimed to compare the sleep-wake patterns measured using the subjectively measured Consensus Sleep Diary (CSD) and the objectively measured ActiGraph (AG) actigraphy among PwPBT.

Methods

Sleep-wake patterns were assessed through CSD and AG over 14 consecutive nights across 2 occasions among 30 PwPBT. AG data were processed with AG proprietary and open-source GGIR (GGIR-based approach without the aid of sleep log algorithms), both with and without the assistance of CSD. Thirteen sleep parameters covering sleep-wake times, sleep disruptions, sleep durations, and sleep efficiency were compared using equivalency testing, mean absolute percent error (MAPE), and intra-class correlation. The estimated sleep parameters were correlated with perceived sleep quality and compared across the different sleep measures.

Results

Significant between-measure equivalency was claimed for sleep-wake time parameters (P ≤ .05), with acceptable MAPEs (<10%). Sleep disruption parameters such as wake-after-sleep-onset were not statistically equivalent, with a large MAPE (≥10%) between the measures. Sleep efficiency was equivalent, though varied depending on how sleep efficiency was calculated. For most sleep parameters, ICCs were low and unacceptable (<0.50) suggesting incomparability between the measures. Lastly, CSD-derived sleep parameters exhibited a stronger correlation with perceived sleep quality compared to actigraphy measures.

Conclusions

The findings suggest the incomparability of sleep parameters estimated from different measures. Both subjective and objective measures are recommended to better describe sleep health among PwPBT.

Temazepam or Melatonin Versus Placebo for the Treatment of Insomnia in Advanced Cancer: A Three-Arm, Double-Blind, Phase III, Multicenter, Randomized Clinical Trial

Background: Sleep disturbance has a prevalence of 30-78% in patients with advanced cancer. While pharmacotherapy is common, randomized controlled studies (RCTs) investigating available agents are limited. This study examines the efficacy and safety of temazepam or melatonin versus placebo for sleep in advanced cancer. Methods: This is a multicenter, randomized, double-blind, placebo-controlled study of temazepam, melatonin prolonged release (PR) or placebo for insomnia in patients with advanced cancer, and an insomnia severity index (ISI) score of >11. Results: Twenty-one participants were randomized: nine to temazepam, eight to melatonin, and four to placebo. Baseline characteristics between groups were similar. The adjusted mean difference in day 8 ISI score versus placebo was -9.1 (95% confidence interval [CI] -17.5, 0.7, p = 0.04) for temazepam and -9.6 (95% CI -18,-1.2, p = 0.03) for melatonin PR. There was no improvement in global quality of life. Both agents were well tolerated. Conclusion: Temazepam and melatonin PR were associated with a clinically significant improvement in patient-reported insomnia severity compared with placebo. Findings need confirmation with larger patient numbers.

Acupuncture-related therapy for cancer-related insomnia: An overview of systematic reviews and meta-analysis

BACKGROUND

The number of systematic reviews and meta-analyses (SRs/MAs) on acupuncture therapy for CRI is increasing; however, the credibility of the evidence remains unclear with controversial results, necessitating a comprehensive evaluation.

OBJECTIVE

We aimed to critically assess the evidence in SRs/MAs regarding the effectiveness of acupuncture therapy for CRI from various aspects and conduct an exploratory analysis to identify potential issues.

METHOD

Two reviewers conducted comprehensive searches in eight databases. SRs/MAs of randomized controlled trials are included. After screening according to inclusion and exclusion criteria, two reviewers extracted data from eligible SRs/MAs and conducted a detailed assessment of methodological quality, risk of bias, and quality of evidence using AMSTAR-2, ROBIS, and GRADE tools. Meanwhile, we calculated the Corrected Covered Area (CCA) leveraging the GROOVE tool. After manually excluding duplicate studies, we assess the risk of bias of primary studies extracted from SRs/MAs and conducted exploratory meta-analysis.

RESULT

The comprehensive analysis included 10 SRs/MAs. The AMSRAT-2 results indicate significant methodological flaws in SRs/MAs, with the main issues focusing on the lack of provision of exclusion checklist for the studies. Furthermore, over half of the SRs/MAs have a high risk of bias due to incomplete retrieval and failure to follow the protocol. Most SRs/MAs demonstrated considerable completeness in reporting quality. Notably, the overall level of evidence is low. High overlap indicates redundant SRs/MAs. Exploratory analysis suggests that acupuncture therapy may be effective for CRI; however, with a high risk of bias, caution is needed in interpreting the results. Sensitivity analysis results are stable, and the funnel plot indicates no publication bias. Most SRs/MAs acknowledge the safety of acupuncture.

CONCLUSION

Currently, the credibility of acupuncture therapy for treating CRI is low and improvements are needed in methodology, risk of bias, and quality of reporting. Acupuncture therapy shows potential but lacks sufficient support; high-level evidence is warranted to elucidate the effectiveness of acupuncture in treating CRI.

Recruitment rates and strategies in exercise trials in cancer survivorship: a systematic review

PURPOSE

Despite clear evidence-based supporting a benefit to exercise on physical and psychological metrics in patients with cancer, recruitment to exercise trials amongst cancer survivors is suboptimal. We explore current recruitment rates, strategies, and common barriers to participation in exercise oncology trials in cancer survivorship.

METHODS

A systematic review was conducted using a pre-defined search strategy in EMBASE, CINAHL, Medline, Cochrane Library, and Web of Science. The search was performed up to 28/02/2022. Screening of titles and abstracts, full-text review, and data extraction was completed in duplicate.

RESULTS

Of the 3204 identified studies, 87 papers corresponding to 86 trials were included. Recruitment rates were highly variable with a median rate of 38% (range 0.52-100%). Trials recruiting prostate cancer patients only had the highest median recruitment rate (45.9%) vs trials recruiting colorectal cancer patients only which had the lowest (31.25%). Active recruitment strategies such as direct recruitment via a healthcare professional were associated with higher recruitment rates (rho = 0.201, p = 0.064). Common reasons for non-participation included lack of interest (46.51%, n (number of studies) = 40); distance and transport (45.3%, n = 39); and failure to contact (44.2%, n = 38).

CONCLUSIONS

Recruitment of cancer survivors to exercise interventions is suboptimal with barriers being predominantly patient-oriented. This paper provides the benchmark for current recruitment rates to exercise oncology trials, providing data for trialists planning future trial design and implementation, optimise future recruitment strategies, and evaluate their own recruitment success against current practice.

IMPLICATIONS FOR CANCER SURVIVORS

Enhanced recruitment to cancer survivorship exercise trials is necessary in facilitating the publication of definitive exercise guidelines, generalisable to varying cancer cohorts.

PROSPERO REGISTRATION NUMBER

CRD42020185968.

The Triad of Sleep, Immunity, and Cancer: A Mediating Perspective

The triadic interplay between sleep, immunity, and cancer represents a growing area of biomedical research with significant clinical implications. This review synthesizes the current knowledge on how sleep influences immune function, the immune system's role in cancer dynamics, and the direct connections between sleep patterns and cancer risk. After a comprehensive overview of the interrelationships among these three domains, the mechanisms of sleep in immune function are described, detailing how sleep regulates the immune system, the effects of sleep duration and quality on immune responses, and the underlying molecular and cellular mechanisms. Also, the complex relationship between immunity and cancer is explored, highlighting the immune system's role in cancer prevention and progression, immune surveillance, tumor microenvironment, and the implications of immunodeficiency and immune modulation on cancer risk. The direct connections between sleep and cancer are then described, presenting epidemiological evidence linking sleep patterns to cancer risk, biological mechanisms that influence cancer development, and the role of sleep disorders in cancer prognosis. The mediating role of sleep between immunity and cancer is highlighted, proposing hypothesized pathways, summarizing evidence from experimental and clinical studies, and evaluating the impact of sleep interventions on immune function and cancer outcomes. This review concludes by discussing the clinical implications and future directions, emphasizing the potential for sleep-based interventions in cancer prevention and treatment, the integration of sleep management in oncology and immunotherapy, and outlining a future research agenda. This agenda includes understanding the mechanisms of the sleep-immunity-cancer interplay, conducting epidemiological studies on sleep and cancer risk, assessing the impact of sleep management in cancer treatment protocols, exploring sleep and tumor microenvironment interactions, and considering policy and public health implications. Through a detailed examination of these interconnected pathways, this review underscores the critical importance of sleep in modulating immune function and cancer outcomes, advocating for interdisciplinary research and clinical strategies to harness this knowledge for improved health outcomes.

Exercise Intervention on Insomnia in Patients with a Cancer: A Systematic Review of the Literature

Cancer is associated with increased muscle weakness, reduced physical functioning, increased fatigue, but also sleep disturbances, including insomnia, that affect quality of life (QoL). Physical activity demonstrated benefits on functional capacity, resilience and cancer-related fatigue, but there is a paucity of available data regarding its effects on insomnia in patients with cancer. This systematic review aims to examine the efficacy of exercise levels with insomnia in cancer patients. A systematic search was performed for articles published in PubMed and Cochrane Library databases from December 2013 to February 2023. Included studies explored insomnia during or after cancer treatment, with various exercise interventions. The search identified nine studies included in this review. Due to substantial heterogeneity in the interventions across studies, meta-analysis was not performed. Three studies reported positive results for insomnia reduction by self-reported outcomes under a supervised aerobic exercise program alone or combined with strength training. The present systematic review establishes the role of exercise interventions for reducing cancer-related insomnia. Further studies are indeed warranted to improve the level of evidence for exercise interventions for implementation in the care of cancer-related insomnia.

Longitudinal associations of diurnal rest-activity rhythms with fatigue, insomnia, and health-related quality of life in survivors of colorectal cancer up to 5 years post-treatment

BACKGROUND

There is a growing population of survivors of colorectal cancer (CRC). Fatigue and insomnia are common symptoms after CRC, negatively influencing health-related quality of life (HRQoL). Besides increasing physical activity and decreasing sedentary behavior, the timing and patterns of physical activity and rest over the 24-h day (i.e. diurnal rest-activity rhythms) could also play a role in alleviating these symptoms and improving HRQoL. We investigated longitudinal associations of the diurnal rest-activity rhythm (RAR) with fatigue, insomnia, and HRQoL in survivors of CRC.

METHODS

In a prospective cohort study among survivors of stage I-III CRC, 5 repeated measurements were performed from 6 weeks up to 5 years post-treatment. Parameters of RAR, including mesor, amplitude, acrophase, circadian quotient, dichotomy index, and 24-h autocorrelation coefficient, were assessed by a custom MATLAB program using data from tri-axial accelerometers worn on the upper thigh for 7 consecutive days. Fatigue, insomnia, and HRQoL were measured by validated questionnaires. Confounder-adjusted linear mixed models were applied to analyze longitudinal associations of RAR with fatigue, insomnia, and HRQoL from 6 weeks until 5 years post-treatment. Additionally, intra-individual and inter-individual associations over time were separated.

RESULTS

Data were available from 289 survivors of CRC. All RAR parameters except for 24-h autocorrelation increased from 6 weeks to 6 months post-treatment, after which they remained relatively stable. A higher mesor, amplitude, circadian quotient, dichotomy index, and 24-h autocorrelation were statistically significantly associated with less fatigue and better HRQoL over time. A higher amplitude and circadian quotient were associated with lower insomnia. Most of these associations appeared driven by both within-person changes over time and between-person differences in RAR parameters. No significant associations were observed for acrophase.

CONCLUSIONS

In the first five years after CRC treatment, adhering to a generally more active (mesor) and consistent (24-h autocorrelation) RAR, with a pronounced peak activity (amplitude) and a marked difference between daytime and nighttime activity (dichotomy index) was found to be associated with lower fatigue, lower insomnia, and a better HRQoL. Future intervention studies are needed to investigate if restoring RAR among survivors of CRC could help to alleviate symptoms of fatigue and insomnia while enhancing their HRQoL.

TRIAL REGISTRATION

EnCoRe study NL6904 ( https://www.onderzoekmetmensen.nl/ ).

Mi Sleep Coach Mobile App to Address Insomnia Symptoms Among Cancer Survivors: Single-Arm Feasibility Study

BACKGROUND

Rates of sleep disturbance among survivors of cancer are more than 3 times higher than the general population. Causes of sleep disturbance among survivors are many and multifaceted, including anxiety and fear related to cancer diagnosis and treatments. Cognitive behavioral therapy for insomnia (CBT-I) is considered a first-line treatment for insomnia; However, a lack of access to trained professionals and limited insurance coverage for CBT-I services has limited patient access to these effective treatments. Evidence supports digital delivery of CBT-I (dCBT-I), but there is only limited evidence to support its use among survivors of cancer. Broad adoption of smartphone technology provides a new channel to deliver dCBT-I, but no prior studies have evaluated mobile dCBT-I interventions for survivors. To address the need for accessible and efficacious CBT-I for survivors of cancer, the Mi Sleep Coach program was developed to adapt CBT-I for delivery to survivors of cancer as a self-directed mobile health app.

OBJECTIVE

This single-arm feasibility study assessed the adherence, attrition, usefulness, and satisfaction of the Mi Sleep Coach app for insomnia.

METHODS

A 7-week, single-arm study was conducted, enrolling adult survivors of breast, prostate, or colon cancer reporting sleep disturbances.

RESULTS

In total, 30 participants were enrolled, with 100% completing the study and providing data through week 7. Further, 9 out of 10 app features were found to be useful by 80% (n=24) to 93% (n=28) of the 30 participants. Furthermore, 27 (90%) participants were satisfied with the Mi Sleep Coach app and 28 (93%) would recommend the use of the Mi Sleep Coach app for those with insomnia. The Insomnia Severity Index showed a decrease from baseline (18.5, SD 4.6) to week 7 (10.4, SD 4.2) of 8.1 (P<.001; Cohen d=1.5). At baseline, 25 (83%) participants scored in the moderate (n=19; 15-21) or severe (n=6; 22-28) insomnia range. At week 7, a total of 4 (13%) patients scored in the moderate (n=4) or severe (n=0) range. The number of patients taking prescription sleep medications decreased from 7 (23%) at baseline to 1 (3%; P<.001) at week 7. The number of patients taking over-the-counter sleep medications decreased from 14 (47%) at baseline to 9 (30%; P=.03) at week 7.

CONCLUSIONS

The Mi Sleep Coach app demonstrated high levels of program adherence and user satisfaction and had large effects on the severity of insomnia among survivors of cancer. The Mi Sleep Coach app is a promising intervention for cancer-related insomnia, and further clinical trials are warranted. If proven to significantly decrease insomnia in survivors of cancer in future randomized controlled clinical trials, this intervention would provide more survivors of cancer with easy access to evidence-based CBT-I treatment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04827459; https://clinicaltrials.gov/study/NCT04827459.

Longitudinal associations of circadian eating patterns with sleep quality, fatigue and inflammation in colorectal cancer survivors up to 24 months post-treatment

Fatigue and insomnia, potentially induced by inflammation, are distressing symptoms experienced by colorectal cancer (CRC) survivors. Emerging evidence suggests that besides the nutritional quality and quantity, also the timing, frequency and regularity of dietary intake (chrono-nutrition) could be important for alleviating these symptoms. We investigated longitudinal associations of circadian eating patterns with sleep quality, fatigue and inflammation in CRC survivors. In a prospective cohort of 459 stage I-III CRC survivors, four repeated measurements were performed between 6 weeks and 24 months post-treatment. Chrono-nutrition variables included meal energy contribution, frequency (a maximum of six meals could be reported each day), irregularity and time window (TW) of energetic intake, operationalised based on 7-d dietary records. Outcomes included sleep quality, fatigue and plasma concentrations of inflammatory markers. Longitudinal associations of chrono-nutrition variables with outcomes from 6 weeks until 24 months post-treatment were analysed by confounder-adjusted linear mixed models, including hybrid models to disentangle intra-individual changes from inter-individual differences over time. An hour longer TW of energetic intake between individuals was associated with less fatigue (β: -6·1; 95 % CI (-8·8, -3·3)) and insomnia (β: -4·8; 95 % CI (-7·4, -2·1)). A higher meal frequency of on average 0·6 meals/d between individuals was associated with less fatigue (β: -3·7; 95 % CI (-6·6, -0·8)). An hour increase in TW of energetic intake within individuals was associated with less insomnia (β: -3·0; 95 % CI (-5·2, -0·8)) and inflammation (β: -0·1; 95 % CI (-0·1, 0·0)). Our results suggest that longer TWs of energetic intake and higher meal frequencies may be associated with less fatigue, insomnia and inflammation among CRC survivors. Future studies with larger contrasts in chrono-nutrition variables are needed to confirm these findings.

Comparison Between Efficacy of Oral Melatonin and Oral L-theanine in Improving Sleep in Cancer Patients Suffering From Insomnia: A Randomised Double-blinded Placebo-controlled Study

Objectives

The primary objective was to compare the hypnotic efficacy of oral melatonin, oral L-theanine, and placebo in improving sleep in cancer patients with insomnia by the Athens Insomnia Scale (AIS). The secondary objective was to know the prevalence of insomnia in patients with cancer.

Materials and Methods

A prospective, double-blinded, placebo-controlled study was conducted after obtaining Institutional Ethics Committee approval. One hundred and twenty patients were randomly assigned to either Group A (melatonin), Group B (L-theanine), or Group C (placebo). They were instructed to take the tablets for 14 consecutive days, two h (hours) before bedtime, and evaluated with AIS on the 1st day, 7th day, and 14th day.

Results

There were seven dropouts: Two in Group A, two in Group B, and three in Group C. Significant differences in favour of melatonin treatment were found. There were statistically significant improvements in insomnia in cancer patients on melatonin intake compared to L-theanine. L-theanine had statistically significant improvements in insomnia in comparison to placebo. The mean ± standard deviation AIS on day one in Group A was 14.82 ± 1.29; on day seven was 10.92 ± 1.12; and on day 14 was 5.00 ± 0.70. Similarly, in Group B, the mean ± standard deviation AIS was 15.39 ± 1.03, 13.05 ± 1.06, and 9.55 ± 1.01, and in Group C, the mean AIS was 14.92 ± 1.40, 14.54 ± 1.35 and 13.05 ± 1.61 on the 1st, 7th and 10th day, respectively. There was an improvement in sleep from 1 to 7 days, 7 days to 14 days, and 1 day to 14 days in all the groups (P < 0.005).

Conclusion

The hypnotic efficacy of oral melatonin 3 mg was better than oral L-theanine 200 mg in cancer patients having insomnia. Furthermore, L-theanine had a better hypnotic efficacy when compared to a placebo.

Self-Completion Questionnaire on Sleep Evaluation in Patients Undergoing Oxaliplatin Therapy: An Observational Study

Sleep is a fundamental human need; sleep disruption, in fact, causes an increase in the activity of the sympathetic nervous system and the hypothalamic-pituitary-adrenal axis, metabolic effects, changes in circadian rhythms, and pro-inflammatory responses. The scientific literature is finally starting to pay attention to the central role of sleep alterations in patients health. Oxaliplatin is extensively used for the treatment of gastrointestinal cancer and other malignancies, with an increased frequency of use in recent years. This study aims to understand the effects of sleep complaints on health and quality of life in cancer patients treated with oxaliplatin. A study has been conducted through the creation and distribution of questionnaires to patients to investigate their complaints about sleep quality. We observed significant differences between males and females in evaluating sleep hygiene scores, the Pittsburgh Sleep Quality Index, and previous difficulty sleeping. Moreover, in females, stress, worries, and anxiety seem to play a negative role in the sleep hygiene score. The obtained results could improve the interest of healthcare personnel and caregivers in sleep quality in patients undergoing chemotherapy.

Efficacy of acupuncture therapy on cancer-related insomnia: a systematic review and network meta-analysis

Objectives

Cancer-related insomnia (CRI) takes a toll on many cancer survivors, causing distressing symptoms and deteriorating the quality of life. Acupuncture therapy has been used for CRI already. However, it is still uncertain which acupuncture regime is best for CRI. The primary objective of this review is to conduct a comparative evaluation and ranking of the effectiveness of different acupuncture therapies for CRI.

Methods

Randomized controlled trials (RCTs) that were published up to July 31, 2023, from 8 databases (PubMed, Embase, Cochrane library, Web of Science, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biology Medicine disc) were integrated in this study. Trials that met the inclusion criteria were evaluated the risk of bias. Pittsburgh sleep quality index (PSQI) was used to assess the efficacy of different acupuncture therapies as the primary outcome. Then, STATA 15, R, and OpenBUGS were applied to perform the network meta-analysis. PRISMA statements were followed in this network meta-analysis.

Results

A total of 37 studies were included in this review, involving 16 interventions with 3,246 CRI participants. Auriculotherapy + moxibustion [surface under the cumulative ranking curve (SUCRA) 98.98%] and auriculotherapy (SUCRA 77.47%) came out top of the ranking, which were more effective than control, medicine, usual care and sham acupuncture.

Conclusion

Auriculotherapy + moxibustion and auriculotherapy + acupuncture emerged as the top two acupuncture regimes for CRI and future studies should pay more attention to CRI.

Clinical trial registration

https://clinicaltrials.gov/, identifier INPLASY202210095.

Time of day bias for biological sampling in studies of mammary cancer

Despite its demonstrated biological significance, time of day is a broadly overlooked biological variable in preclinical and clinical studies. How time of day affects the influence of peripheral tumors on central (brain) function remains unspecified. Thus, we tested the hypothesis that peripheral mammary cancer tumors alter the transcriptome of immune responses in the brain and that these responses vary based on time of day; we predicted that time of day sampling bias would alter the interpretation of the results. Brain tissues collected at mid dark and mid light from mammary tumor-bearing and vehicle injected mice were analyzed using the Nanostring nCounter immune panel. Peripheral mammary tumors significantly affected expression within the brain of over 100 unique genes of the 770 represented in the panel, and fewer than 25% of these genes were affected similarly across the day. Indeed, between 65 and 75% of GO biological processes represented by the differentially expressed genes were dependent upon time of day of sampling. The implications of time-of-day sampling bias in interpretation of research studies cannot be understated. We encourage considering time of day as a significant biological variable in studies and to appropriately control for it and clearly report time of day in findings.

Standardized Extract of Valeriana officinalis Improves Overall Sleep Quality in Human Subjects with Sleep Complaints: A Randomized, Double-Blind, Placebo-Controlled, Clinical Study

INTRODUCTION

Sleep deficit or poor sleep leads to ill-health, whereas sleep deprivation for longer periods of time increases the risk of developing adverse conditions associated with poor quality of life, and high socioeconomic impact. The treatments for sleep disturbances include melatonin and over-the-counter medicines like diphenhydramine and doxylamine, all of which have negative side effects. Valerian (Valeriana officinalis L.) is a traditional herb and the most preferred alternate sleep solution to manage sleep complaints.

METHODS

Eighty adult subjects with sleep complaints were randomized in 1:1 ratio to receive either V. officinalis extract (VE) or placebo for 8 weeks in a double-blind, placebo-controlled, parallel, clinical study. Primary efficacy endpoints included the Pittsburgh Sleep Quality Index (PSQI) and sleep latency using wrist actigraphy (WA), as well as a number of secondary endpoints, including sleep parameters such as actual sleep time and sleep efficiency using WA, the Epworth Sleepiness Scale (ESS), the Beck Anxiety Inventory (BAI), the Visual Analogue Scale (VAS) for the feeling of waking up refreshed, and a tertiary endpoint of sleep parameters using polysomnography (PSG) in a subset of 20 subjects per group. Safety parameters included physical examination, vital sign measurements, hematology, and clinical chemistry tests. Adverse events and serious adverse events were monitored throughout the study period.

RESULTS

Seventy-two subjects (35 and 37 subjects in the placebo and VE groups, respectively) completed the study and were included in the efficacy assessments. On Days 14, 28, and 56, the PSQI Total Score in the VE group decreased significantly (p < 0.05) compared to the placebo group. Further, the VE group showed significant improvements (p < 0.05) in sleep latency and actual sleep time on Days 3, 14, 28, and 56, and sleep efficiency on Days 14, 28, and 56, as evaluated by WA. There was a decrease (p < 0.05) in anxiety (BAI) on Days 14, 28, and 56, daytime drowsiness (ESS) on Days 28 and 56, and an increased feeling of waking up refreshed (VAS) on Days 28 and 56 compared to placebo. PSG results carried out in subset of subjects revealed significant improvements (p < 0.05) in total sleep time, sleep latency, and sleep efficiency on Day 56 in the VE group compared to the placebo group. No safety concerns were observed throughout the study.

CONCLUSION

VE supplementation significantly improved various subjective and objective parameters of sleep in young subjects with mild insomnia symptoms, such as overall sleep quality, sleep latency, sleep efficiency, and total sleep time. We also observed decreased anxiety and daytime sleepiness, and improved feeling of being refreshed after waking up with VE supplementation. VE was found to be safe and well tolerated throughout the study.

TRIAL REGISTRATION

Clinical Trials Registry of India: CTRI/2022/05/042818.

The Sleepio After Cancer (SAC) study. Digital cognitive behavioural therapy for insomnia (dCBT-I) in women cancer patients - Trial protocol of a randomised controlled trial

AIMS

This study will assess the efficacy of digital CBT for insomnia (dCBT-I) compared to sleep hygiene education (SHE) for the management of insomnia in women with cancer.

BACKGROUND

30% of patients with cancer meet insomnia diagnostic criteria and this can be detrimental to health outcomes. Insomnia disorder comprises a dissatisfaction with sleep quantity or quality characterized by difficulty initiating sleep, frequent awakenings, or early morning wakening without the ability to return to sleep, at least 3 nights per week, for at least 3 months, causing significant impairment or distress in areas of functioning.

METHODS

We will recruit 308 women with a current or prior cancer diagnosis who are currently experiencing insomnia; defined as a score of 16 or less on the Sleep Condition Indicator (SCI). Participants will be randomised to dCBT-I or SHE. dCBT-I will be delivered online via 6 sessions. SHE will be provided in an online format. Assessments of sleep and other related parameters, through validated questionnaires, will be taken at 12 and 24 weeks following intervention. Once 24 week assessments are completed, participants will crossover to the alternate arm (either SHE or dCBT-I) and undergo a final assessment at week 36.

OUTCOMES

The primary outcome will be the mean continuous change in SCI score in the intervention arm compared to the control arm at 24 weeks. Additionally, the proportion of women with an SCI > 16 at 24 weeks will be assessed. Secondary outcomes include fatigue, sleep related quality of life, depression, anxiety, and hot flush interference.

REGISTRATION

This study is registered on ClinicalTrials.gov with number NCT05816460.

Insomnia in adult patients with cancer: ESMO Clinical Practice Guideline

•Insomnia is common in patients with cancer, with a higher prevalence than observed in the general population. •Insomnia is often under-recognised and inadequately treated in patients with cancer. •Brief validated screening tools are available for the evaluation of insomnia in clinical practice. •First-line therapy should be based on international guidelines recommending cognitive behavioural therapy for insomnia.

Acupuncture improves certain aspects of sleep in hematopoietic stem cell transplantation patients: a secondary analysis of a randomized controlled trial

BACKGROUND

High-dose chemotherapy followed by hematopoietic stem cell transplantation (HSCT) is associated with a high symptom burden including sleep disturbance. Here we present the results of a secondary analysis of a randomized, sham-controlled trial assessing the effect of acupuncture on sleep quality during HSCT.

METHODS

Adult multiple myeloma patients undergoing inpatient and outpatient autologous HSCT were randomized and blinded to receive either true or sham acupuncture (by licensed acupuncturists) once daily for 5 days starting the day after chemotherapy. Sleep onset, total sleep time, sleep efficiency percentage and sleep-onset latency time were assessed using an actigraphy-based sleep monitor. A multivariate regression analysis was conducted to compare the average area-under-the-curve of five acupuncture intervention days for each sleep outcome between groups, adjusted by baseline score and inpatient or outpatient chemotherapy stratum.

RESULTS

Over 32 months, 63 patients were enrolled. Participants undergoing true acupuncture experienced a significant improvement in sleep efficiency when compared to sham (-6.70, 95% CI -13.15, -0.25, p = 0.042). Subgroup analysis showed that the improvement was more prominent in the inpatient setting (-9.62, 95% CI -18.76, -0.47; p = 0.040). True acupuncture tended to improve wake time after sleep onset (WASO; -10.95, p = 0.054). Between-group differences in other sleep related variables were not statistically significant.

CONCLUSION

Our data suggest that true acupuncture may improve certain aspects of sleep, including sleep efficiency and possibly WASO, in multiple myeloma patients undergoing HSCT. By studying patient reported outcomes in future larger scale studies, acupuncture's role in improving sleep quality during HSCT treatment could be further elucidated.

TRIAL REGISTRATION NUMBER

NCT01811862 (ClinicalTrials.gov).

Post-Operative Poor Sleep Quality and Its Associated Factors Among Non-Small Cell Lung Cancer Patients: A Cross-Sectional Study

Objective

The study aimed to determine the post-operative prevalence and factors associated to poor sleep quality in non-small cell lung cancer (NSCLC) patients in China.

Methods

NSCLC patients (n=307) who underwent thoracoscopic surgery at the Department of Thoracic Surgery of Shanghai Pulmonary Hospital were enrolled in this study. The Pittsburgh Sleep Quality Index (PSQI), Generalized Anxiety Disorder-7 (GAD-7), Patient Health Questionnaire-9 (PHQ-9), Prince Henry Hospital Pain Score and the Six-Minute Walk Test (6MWT), and Forced Expiratory Volume in one second (FEV-1) were used to assess the factors that could lead to poor sleep quality. All assessments were carried out between April 1 and May 30, 2023. Descriptive analyses and stepwise factor regression were employed to determine the impact of various factors on sleep quality. The factors predictive of poor sleep quality were used to develop a predictive nomogram. The Hosmer-Lemeshow test was used to assess the predictive value of the nomogram.

Results

The median PQSI score was 8 (interquartile range (IQR) 5-12), and 74.6% of patients had poor sleep quality. The median anxiety and depression scores were 6 (IQR 3-9) and 4 (IQR 2-7), respectively. The PSQI latency dimension had the highest score, while the use of sleep medications dimension had the lowest score. The multivariate analysis revealed that patients who were female (OR, 2.38; 95% CI, 1.40-4.05; P <0.01), had post-secondary education (OR, 0.42; 95% CI, 0.19-0.92; P =0.03), tertiary education (OR, 0.38; 95% CI, 0.17-0.84; P =0.02), comorbidities (OR, 2.57; 95% CI, 1.51-4.39; P <0.01), a pain score 1 (OR, 4.22; 95% CI, 2.37-7.50; P <0.01), and cough (OR, 2.97; 95% CI, 1.63-5.40; P <.001) were more like to experience poor sleep quality. The positive predictive value of the nomogram was 79.80% (p=0.390).

Conclusion

Sociodemographic variables, comorbidities, and pain could be used to predict the post-operative sleep quality in NSCLC patients.

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.

Factors associated with the sleep disturbances of people with breast cancer during chemotherapy in China: A cross-sectional study

AIM

The aim of the study was to investigate the incidence of sleep disturbance and its relationship with anxiety and depression symptoms, social support and hope in breast cancer patients in China during chemotherapy.

DESIGN

A single-centre cross-sectional study.

METHODS

A total of 329 breast cancer patients were selected via convenience sampling method before they began chemotherapy (n = 115), before the 5th week of chemotherapy (n = 117) or 1 month after chemotherapy ended (n = 97) and administered paper-and-pencil questionnaires to evaluate sleep quality, depression and anxiety symptoms, social support and hope. Risk factors significantly associated with sleep disturbance during bivariate were incorporated in the multivariate analysis. Bivariate analyses showed that age, menopausal status, depression and anxiety symptoms, emotional/informational support, tangible support, affectionate support, positive social interaction and total support were predictors of sleep disturbance.

RESULTS

Sleep disturbance was prevalent in breast cancer patients before (27.0%), during (32.5%) and after (39.2%) chemotherapy, with 37.4%, 41.9% and 52.6% of participants, respectively, reporting sleeping below the recommended 7 h. Only 8.6%-15.5% of patients reported taking sedative-hypnotic drugs during the chemotherapy. Multivariate analyses found that participants reporting clinically significant anxiety (HADS > 8) were 3.5 times more likely to report sleep disturbance (PSQI > 8) than participants without clinically significant anxiety, and each increment in emotional/informational support was associated with a 9.04% reduced risk of sleep disturbance. Moreover, age was an independent predictor of sleep disturbance during multivariate modelling.

Understanding Sleep Disturbances in Prostate Cancer-A Scientometric Analysis of Sleep Assessment, Aetiology, and Its Impact on Quality of Life

Prostate cancer is the most commonly diagnosed cancer in the United Kingdom. While androgen-deprivation therapy is the most common treatment for prostate cancer, patients undergoing this treatment typically experience side effects in terms of sleep disturbances. However, the relation between prostate cancer and sleep and the way in which sleep interventions may benefit oncological patients is underinvestigated in the literature. The current study aims to review in a data-driven approach the existing literature on the field of prostate cancer and sleep to identify impactful documents and major thematic domains. To do so, a sample of 1547 documents was downloaded from Scopus, and a document co-citation analysis was conducted on CiteSpace software. In the literature, 12 main research domains were identified as well as 26 impactful documents. Research domains were examined regarding the link between prostate cancer and sleep, by taking into account variations in hormonal levels. A major gap in the literature was identified in the lack of use of objective assessment of sleep quality in patients with prostate cancer.

Effect of acupuncture versus usual care on sleep quality in cancer survivors with chronic pain: Secondary analysis of a randomized clinical trial

BACKGROUND

Chronic pain negatively affects sleep; it is unclear whether pain relief from acupuncture contributes to sleep quality improvements in cancer survivors. This study aimed to evaluate the effect of acupuncture versus usual care on sleep quality among cancer survivors with comorbid sleep disturbance and chronic musculoskeletal pain.

METHODS

Sleep outcome data from the Personalized Electroacupuncture Versus Auricular Acupuncture Comparative Effectiveness (PEACE) randomized clinical trial were analyzed. Electroacupuncture or auricular acupuncture was compared with usual care for sleep quality improvement over 10 weeks of treatment among cancer survivors with clinically significant sleep disturbance and chronic musculoskeletal pain at baseline. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI) global score.

RESULTS

Among 268 participants (mean [standard deviation (SD)] age, 61.4 [12.6] years; 191 women [71.3%]; mean [SD] baseline PSQI global score, 10.3 [3.3] points), electroacupuncture and auricular acupuncture resulted in greater reductions in the PSQI global score from baseline to 10 weeks in comparison with usual care: 1.42 points (95% confidence interval [CI], 0.45-2.38; p = .004) and 1.59 points (95% CI, 0.62-2.55; p = .001), respectively. The improvement in sleep quality for the acupuncture groups was sustained for 24 weeks from randomization. Furthermore, a greater proportion of patients in the electroacupuncture and auricular acupuncture groups had clinically meaningful improvement in sleep quality compared to the usual care group (41.0% and 42.9% vs. 21.4%; p = .044).

CONCLUSIONS

Among cancer survivors with comorbid sleep disturbance and chronic pain, electroacupuncture and auricular acupuncture produced a clinically relevant and persistent improvement in sleep quality. These findings suggest that acupuncture may be an evidence-based nonpharmacologic intervention to improve sleep health for cancer survivors with pain.

PLAIN LANGUAGE SUMMARY

This study analyzed the sleep quality data from a published randomized clinical trial that evaluated the effect of electroacupuncture or auricular acupuncture versus usual care on pain relief among people who survived cancer. This analysis included a prespecified subgroup of 268 participants with co-occurring sleep disturbance and chronic musculoskeletal pain at baseline and found that patients who used acupuncture for pain relief demonstrated greater improvements in sleep quality compared with patients who received usual care. Sleep quality improvement by acupuncture was sustained after the treatment ended.

Tackling Insomnia Symptoms through Vestibular Stimulation in Patients with Breast Cancer: A Perspective Paper

Insomnia symptoms are common among patients with breast cancer (BC; 20-70%) and are predictors of cancer progression and quality of life. Studies have highlighted sleep structure modifications, including increased awakenings and reduced sleep efficiency and total sleep time. Such modifications may result from circadian rhythm alterations consistently reported in this pathology and known as carcinogenic factors, including lower melatonin levels, a flattened diurnal cortisol pattern, and lower rest-activity rhythm amplitude and robustness. Cognitive behavioral therapy and physical activity are the most commonly used non-pharmacological interventions to counter insomnia difficulties in patients with BC. However, their effects on sleep structure remain unclear. Moreover, such approaches may be difficult to implement shortly after chemotherapy. Innovatively, vestibular stimulation would be particularly suited to tackling insomnia symptoms. Indeed, recent reports have shown that vestibular stimulation could resynchronize circadian rhythms and improve deep sleep in healthy volunteers. Moreover, vestibular dysfunction has been reported following chemotherapy. This perspective paper aims to support the evidence of using galvanic vestibular stimulation to resynchronize circadian rhythms and reduce insomnia symptoms in patients with BC, with beneficial effects on quality of life and, potentially, survival.

Significance of music therapy in treating depression and anxiety disorders among people with cancer

Globally, cancer cases and mortality have recently escalated and have attracted global concern. The clinical diagnosis and manifestation of cancer can result in significant mental health issues like depression and anxiety disorders. The tendency of people with cancer to suffer from psychological disorders such as anxiety and depression is usually high. A significant number of deaths related to cancer may likely not be from the killer disease but from psychological disorders associated with the illness. The utilization of music as a remedial approach to healing mental disorders cannot be overstated. Thus, identifying the impacts of music therapy in dealing with depression and anxiety disorders among people with cancer is relevant, as the majority of methods used in treating cancer have some side effects which may trigger psychological disorders in cancer patients. Ultimately, this study explored the significance of music therapy in treating depression and anxiety disorders among people with cancer. To achieve the aim of this study, the authors employed a narrative literature review to investigate the significance of music therapy in addressing depression and anxiety disorders among people with cancer. The type of literature review employed in this study is to provide an understanding of the selected research papers. The review found that music therapy significantly reduces depression and anxiety disorders among breast cancer, lung cancer, prostate cancer, and colorectal cancer patients. It is needful for healthcare providers to incorporate music therapy interventions while treating people with cancer. This will help reduce cancer deaths resulting from psychological disorders rather than the killer disease, cancer. However, the standardized procedures and evaluation criteria for applying music-based intervention strategies in oncology medicine still need to be further established and improved.

Perception of disease, dyadic coping, and the quality of life of oncology patients in the active treatment phase and their life partners: an approach based on the actor-partner interdependence model

Objective

The aim of this study based on the Systemic Transactional Model was to examine the relationship between dyadic coping and (1) disease perception and (2) quality of life of a sample of cancer patients and their life partners.

Method

This cross-sectional study included 138 oncological dyads. The following questionnaires were used: Stress Appraisal Measure, Dyadic Coping Inventory, and European Organisation for Research and Treatment of Cancer QLQ-C30. Data collected was analysed by applying the actor-partner interdependence model.

Results

The perception of the disease as a threat as well as its centrality significantly negatively influences the positive forms of dyadic coping whilst the perception of the disease as a challenge has a significant positive influence on them. Dyadic coping does not influence symptoms but has significant influences on global health/quality of life.

Conclusion

This study has highlighted new information regarding how couples cope with cancer. The results encourage the inclusion of the perception of the disease and dyadic coping in interventions that aim to improve the quality of life of cancer patients and their life partners.

Zopiclone versus placebo for short-term treatment of insomnia in patients with advanced cancer-a double-blind, randomized placebo-controlled clinical multicenter phase IV trial

PURPOSE

Insomnia is frequent in patients with advanced cancer, and a variety of pharmacological agents is used to treat this condition. Still, few clinical trials have investigated the effectiveness of pharmacological sleep therapies in this patient group. We aimed to study the short-term effectiveness of zopiclone on sleep quality in patients with advanced cancer who report insomnia.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group, multicenter, phase IV clinical trial in adult patients with metastatic malignant disease and insomnia. Patients were treated with zopiclone or placebo for six subsequent nights. Primary end point was patient-reported sleep quality during the final study night (NRS 0-10). Secondary end points were patient-reported sleep onset latency (SOL) and total sleep time (TST).

RESULTS

Forty-one patients were randomized, with 18 being analyzed in the zopiclone group and 21 in the placebo group. Median age was 66, median Karnofsky performance score was 80, and 56% were male. Mean sleep quality at end of study was 2.9 (CI 2.3 to 3.8) in the zopiclone group and 4.5 (CI 3.6 to 5.4) in the placebo group (p = 0.021). At end of study, SOL was significantly different between the treatment groups: zopiclone 29 min (CI 13 to 51) and placebo 62 min (CI 40 to 87) (p = 0.045). TST was not significantly different across groups: zopiclone 449 min (403 to 496) and placebo 411 min (CI 380 to 440) (p = 0.167).

CONCLUSION

Zopiclone improved short-term patient-reported sleep quality in this cohort of patients with advanced cancer.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02807922.

Comparative efficacy and acceptability of interventions for insomnia in breast cancer patients: A protocol for systematic review and network meta-analysis

BACKGROUND

Symptoms of insomnia are highly prevalent in patients with breast cancer. There are a large number of pharmacological and non-pharmacological interventions that can be used for the management of insomnia in breast cancer patients; however, their comparative effectiveness and acceptability remain uncertain. This review aims to evaluate the efficacy and acceptability of different interventions for insomnia in breast cancer patients using a Bayesian network meta-analysis (NMA).

METHODS

We will perform a comprehensive literature search in PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, and PsycINFO from inception to November 2022. We will include randomized controlled trials (RCTs) that compared the effects of different interventions on the management of insomnia in breast cancer patients. We will assess the risk of bias assessment using a modified Cochrane instrument. We will conduct a Bayesian random-effects framework NMA to estimate relative effects of interventional procedures. We will use Grading of Recommendations Assessment, Development and Evaluation to rate the certainty of evidence.

DISCUSSION

To our knowledge, this will be the first systematic review and network meta-analysis to compare the effectiveness and acceptability of all currently available interventions for insomnia in patients with breast cancer. The results of our review will help provide more evidence for the treatment of insomnia in breast cancer patients.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number CRD42021282211.

Comparative efficacy of different acupuncture therapies on cancer-related insomnia: protocol for a systematic review and network meta-analysis

INTRODUCTION

Cancer-related insomnia (CRI), as a common complication in cancer survivors, may further lead to depression, anxiety and other symptoms. Acupuncture therapy is a promising therapeutic strategy for CRI. The effectiveness of acupuncture therapy on CRI has been validated by several relevant meta-analyses. Questions remain, however, including which acupuncture regimen is optimal. We aim to conduct the first network meta-analysis to compare different acupuncture therapies, rank their effectiveness and assess which approach could be optimal for treatment of CRI.

METHODS AND ANALYSIS

A comprehensive search of PubMed, Cochrane Library, Web of Science, Embase, China National Knowledge Infrastructure, Wanfang Database, VIP Database (China Science and Technology Journal Database), and China Biology Medicine (from inception until 1 March 2022) will be carried out to identify randomised controlled trials (RCTs) of acupuncture therapy for insomnia in cancer survivors, reported in English or Chinese. Reviews, animal studies, non-RCT studies, editorials and other secondary insomnia studies will be excluded. The primary outcome measure will be the Pittsburgh Sleep Quality Index. Pairwise meta-analysis will be performed in Stata and network meta-analysis by OpenBUGS, R and Stata. Network plots and funnel plots will be used to show the scale of studies and participants for each intervention and the potential publication bias, respectively. Both heterogeneity and consistency will be evaluated by R. ORs with 95% CIs and mean differences with 95% CI will be calculated in OpenBUGS and transformed into league figure and surface under the cumulative ranking by Stata to visualise the results.

ETHICS AND DISSEMINATION

Ethical committee approval for this review is unnecessary since the data used will be extracted from pre-existing literature. The results will be submitted for publication in a peer-reviewed journal and presented at international academic conferences.

Surveillance of long-term complications after treatment of adult brain tumor survivors-review and evidence-based recommendations

As a result of treatment and diagnosis, adults with primary or metastatic brain tumors experience comorbidities that impacts their health and well-being. The Children's Oncology Group has guideline recommendations for childhood survivors of brain tumors; however, guidelines for monitoring long-term sequela among adult brain tumor survivors are lacking. The purpose of this review is to present the screening recommendations for the long-term complications after brain tumor treatment from a multidisciplinary panel of healthcare professionals. Chronic complications identified include cognitive dysfunction, vasculopathy, endocrinopathy, ophthalmic, ototoxicity, physical disability, sleep disturbance, mood disorder, unemployment, financial toxicity, and secondary malignancy. We invited specialists across disciplines to perform a literature search and provide expert recommendations for surveillance for long-term complications for adult brain tumor survivors. The Brain Tumor Center Survivorship Committee recommends routine screening using laboratory testing, subjective assessment of symptoms, and objective evaluations to appropriately monitor the complications of brain tumor treatments. Effective monitoring and treatment should involve collaboration with primary care providers and may require referral to other specialties and support services to provide patient-centered care during neuro-oncology survivorship. Further research is necessary to document the incidence and prevalence of medical complications as well as evaluate the efficacy of screening and neuro-oncology survivorship programs.

Distinct sleep disturbance and cognitive dysfunction profiles in oncology outpatients receiving chemotherapy

PURPOSE

Sleep disturbance and cancer-related cognitive impairment (CRCI) are two of the most common symptoms reported by patients undergoing chemotherapy. Less is known about how these symptoms co-occur and their associated risk factors. Study purposes were to identify subgroups of patients with distinct sleep disturbance and CRCI profiles and evaluate for differences among the subgroups in demographic and clinical characteristics, symptom severity scores, and QOL outcomes.

METHODS

A total of 1,333 oncology outpatients receiving chemotherapy completed self-report questionnaires on sleep disturbance and cognitive dysfunction six times over two cycles of chemotherapy. Latent profile analysis was used to identify distinct sleep disturbance AND cognitive dysfunction profiles. Parametric and non-parametric tests were used to evaluate for differences among the classes.

RESULTS

Two distinct profiles were identified (i.e., Low = low levels of both sleep disturbance and cognitive dysfunction (53.5%); High = high levels of both sleep disturbance and cognitive dysfunction (45.5%)). Patients in the High class were younger, more likely to be female, had a lower functional status and a higher level of comorbidity. In addition, these patients had a higher symptom burden and a lower quality of life.

CONCLUSION

Almost half of the patients undergoing chemotherapy experienced clinically meaningful levels of both symptoms. Of note, sleep disturbance is frequently overlooked by both clinicians and patients. Clinicians need to recommend cognitive rehabilitation and physical activity programs to decrease patients' symptom burden.

Cognitive behavior therapy for insomnia in cancer patients: a systematic review and network meta-analysis

OBJECTIVE

The aim of this study was to examine the most effective delivery format of cognitive behavioral therapy for insomnia (CBT-I) on insomnia in cancer patients.

METHODS

We searched five databases up to February 2021 for randomized clinical trials that compared CBT-I with inactive or active controls for insomnia in cancer patients. Outcomes were insomnia severity, sleep efficiency, sleep onset latency (SOL), wake after sleep onset (WASO), and total sleep time (TST). Pairwise meta-analyses and frequentist network meta-analyses with the random-effects model were applied for data analyses.

RESULTS

Sixteen unique trials including 1523 participants met inclusion criteria. Compared with inactive control, CBT-I could significantly reduce insomnia severity (mean differences [MD] = -4.98 points, 95% confidence interval [CI]: -5.82 to -4.14), SOL (MD = -12.29 min, 95%CI: -16.48 to -8.09), and WASO (MD = -16.58 min, 95%CI: -22.00 to -11.15), while increasing sleep efficiency (MD = 7.62%, 95%CI: 5.82% to 9.41%) at postintervention. Compared with active control, CBT-I could significantly reduce insomnia severity (MD = -2.75 points, 95%CI: -4.28 to -1.21), SOL (MD = -13.56 min, 95%CI: -18.93 to -8.18), and WASO (MD = -6.99 min, 95%CI: -11.65 to -2.32) at postintervention. These effects diminished in short-term follow-up and almost disappeared in long-term follow-up. Most of the results were rated as "moderate" to "low" certainty of evidence. Network meta-analysis showed that group CBT-I had an increase in sleep efficiency of 10.61%, an increase in TST of 21.98 min, a reduction in SOL of 14.65 min, and a reduction in WASO of 24.30 min, compared with inactive control at postintervention, with effects sustained at short-term follow-up.

CONCLUSIONS

CBT-I is effective for the management of insomnia in cancer patients postintervention, with diminished effects in short-term follow-up. Group CBT-I is the preferred choice based on postintervention and short-term effects. The low quality of evidence and limited sample size demonstrate the need for robust evidence from high-quality, large-scale trials providing long-term follow-up data.

The effect of a combined treatment of foot soak and lavender oil inhalation therapy on the severity of insomnia of patients with cancer: Randomized interventional study

OBJECTIVES

This three-arm randomized intervention study was carried out with the aim to evaluate the effects of a combined foot soak and lavender oil inhalation therapy on the severity of insomnia of patients with cancer.

METHOD

This research was carried out in oncology and palliative services. Forty-five patients were randomly assigned to three groups. Throughout a 14-day period, 20 min of foot soak treatment was applied to the patients in the F group, patients in the L group were applied lavender oil inhalation therapy for 5 min and a combined treatment of foot soak and lavender oil inhalation therapy were applied to the patients in the FL group. Insomnia severity of the patients in all groups were evaluated twice using the Insomnia Severity Index at the baseline and on the fifteenth day.

RESULTS

The severity of the insomnia of the patients in all groups was found to be moderate. The severity of the insomnia in the second evaluation was found to be statistically significantly lower in the L and FL groups (p<0.05) compared to the baseline evaluation within the group, however no significant difference was found in the F group (p>0.05). The effect size of a combined treatment of foot soak and lavender oil inhalation therapy on the severity of insomnia of patients in the FL group was higher and moderate (d = 0.684) compared to merely foot soak and merely lavender oil inhalation therapy.

CONCLUSION

A combined treatment of foot soak and lavender oil inhalation therapy shall mitigate the severity of a moderate level of insomnia of patients with cancer.

An Update on Prevalence, Assessment, and Risk Factors for Sleep Disturbances in Patients with Advanced Cancer—Implications for Health Care Providers and Clinical Research

Simple Summary

This review focuses on sleep in patients with advanced cancer. Cancer patients experience multiple symptoms and they receive concomitant medications. These are all factors that may affect sleep. In this paper, we present recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that may contribute to insomnia. Sleep is an essential aspect of health-related quality of life; therefore, it is important for health care providers to focus on sleep to improve patient care.

Abstract

Patients with advanced cancer experience multiple symptoms, with fluctuating intensity and severity during the disease. They use several medications, including opioids, which may affect sleep. Sleep disturbance is common in cancer patients, decreases the tolerability of other symptoms, and impairs quality of life. Despite its high prevalence and negative impact, poor sleep quality often remains unrecognized and undertreated. Given that sleep is an essential aspect of health-related quality of life, it is important to extend both the knowledge base and awareness among health care providers in this field to improve patient care. In this narrative review, we provide recommendations on sleep assessment in patients with advanced cancer and highlight cancer-related factors that contribute to insomnia. We also present direct implications for health care providers working in palliative care and for future research.

Association between Preexisting Sleep Disorders and Oncologic Outcome in Patients with Oral Cavity Squamous Cell Carcinoma: A Nationwide Propensity Score-Matched Population-Based Cohort Study

Purpose: To investigate the effects of preexisting sleep disorders on the oncologic outcomes of patients receiving standard treatments for oral squamous cell carcinoma (OSCC). Methods: The patients recruited from the Taiwan Cancer Registry Database who had received surgery for stage I−IVB OSCC. The Cox proportional hazards model was used to analyze all-cause mortality, locoregional recurrence (LRR), and distant metastasis (DM). The patients were categorized into those with and without sleep disorders (Groups 1 and 2, respectively) through propensity score matching. Results: In the multivariate Cox regression analysis, the adjusted hazard ratios for all-cause mortality, LRR, and DM for Group 1 compared with Group 2 were 1.19 (95% confidence interval (CI): 1.04−1.36; p = 0.011), 1.47 (95% CI: 1.23−1.75; p < 0.001), and 1.15 (95% CI: 1.02−1.44; p = 0.025), respectively. Conclusion: OSCC patients with sleep disorders demonstrated poorer oncologic outcomes than did those without sleep disorders. Therefore, before OSCC surgery, patients with OSCC should be screened for preexisting sleep disorders because they may serve as predictors for survival in these patients. Future studies investigating the survival benefits of pharmacological and behavioral treatments for sleep problems in patients with OSCC are warranted.

Prevalence of Sleep Disturbance in Patients With Cancer: A Systematic Review and Meta-Analysis

Sleep disturbance is one of the most common and troubling symptoms that harm the quality of life throughout all phases of treatment and stages of the illness among patients with cancer. The aim of this meta-analysis is to examine the present status of sleep disturbance prevalence in patients with cancer. The following databases were searched: PubMed, CINAHL, MEDLINE, EMBASE, PsycINFO, from inception to April 2021. Prevalence rates were pooled with meta-analysis using a random-effects model. A total of 160 studies (N = 46,279) published between 1998 and 2021 met the inclusion criteria. The overall prevalence of sleep disturbance was 60.7% (26,448/46,279 participants, 95% CI 58.1-63.3%) with significant heterogeneity between studies (p < .000, τ2 = .0000, I2 = 96.4%). This meta-analysis highlights the importance of developing optimal monitoring strategies to reduce sleep disturbance and improve the quality of life of cancer patients.

A Pilot Study Testing the Efficacy of dCBT in Patients With Cancer Experiencing Sleep Problems

Objective

This pilot study aimed to evaluate the efficacy of a digital cognitive behavioral therapy (dCBT) in patients with cancer experiencing sleep problems.

Methods

A total of 57 participants aged 25–65 years (6M/51F with a mean of 42.80 years and a standard deviation of 14.15 years) were randomly assigned to three groups—21 participants to a dCBT program (HARUToday Sleep), 20 participants to an app-based attentional control program (HARUCard Sleep), and 16 participants to a waitlist control group—and evaluated offline before and after the program completion. Of the 57 participants, there were a total of 45 study completers, 15 participants in each group. The dependent variables were sleep quality scores, measured by the Pittsburgh Sleep Quality Index (PSQI) and health-related quality of life scores, measured using the Short-Form 36 (SF-36), and attentional bias scores from a dot-probe computer task.

Results

For both the intention-to-treat (N = 57) and study-completers analyses (N = 45, 15 for each group), a significant increase supported by a large effect size was found in the quality of sleep score of the HARUToday Sleep group compared to both the app-based attentional control and the waitlist control group. However, no significant changes were found in the quality of life and attentional bias scores.

Conclusion

Our results suggest that the HARUToday Sleep app has the potential to serve as an intervention module to enhance the sleep quality of patients with cancer experiencing sleep problems.

Association of Acupuncture and Auricular Acupressure With the Improvement of Sleep Disturbances in Cancer Survivors: A Systematic Review and Meta-Analysis

Background

Studies on the efficacy of acupuncture and auricular acupressure on sleep disturbances in cancer patients have been growing, but there is no specific and comprehensive systematic review and meta-analysis. This review aims to evaluate the efficacy and safety of acupuncture and auricular acupressure on sleep disturbances in cancer survivors based on existing randomized clinical trials (RCTs).

Methods

Four English-language and four Chinese-language biomedical databases were searched for RCTs published from database inception to July 30, 2021. RCTs comparing acupuncture and auricular acupressure with sham control, drug therapy, behavior therapy, or usual care for managing cancer were included. The quality of RCTs was appraised with the Cochrane Collaboration risk of bias (ROB) tool. Mean differences (MDs) and 95% confidence intervals (CIs) were calculated for the effect sizes.

Results

Thirteen RCTs with 961 patients were included. The risk of performance bias or reporting bias for most of the included trials was high or unclear. Evidence was not found for short-term effects on sleep scales compared to sham control (MD, 1.98; 95% CI, 0.33-3.64; p = 0.02; I² = 36%), wait list control (MD, 0.40; 95% CI, -0.87-1.68; p = 0.54; I² = 49%), drug therapy (MD, 1.18; 95% CI, -3.09-5.46; p = 0.59; I² = 98%). For long-term effect, two sham-controlled RCTs showed no significance of acupuncture on insomnia scale scores (MD, 1.71; 95% CI, -2.38-5.81; p = 0.41; I² = 89%). Subgroup analyses suggested no evidence that auricular acupressure (MD, 3.14; 95% CI=1.52, 4.76; p = 0.0001; I² = 0%) or acupuncture (MD, 0.54; 95% CI=-1.27, 2.34; p = 0.56; I² = 0%) was associated with the reduction in insomnia scale scores.

Conclusions

This systematic review and meta-analysis found no evidence about acupuncture or auricular acupressure in the improvement of sleep disturbances in cancer survivors in terms of short- or long-term effect. Adverse events were minor. The finding was inconsistent with previous research and suggested that more well-designed and large-scale randomized controlled trials are needed to identify the efficacy of acupuncture and auricular acupressure for sleep disturbances in cancer survivors.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42020171612.

Insomnia and circadian sleep disorders in ovarian cancer: Evaluation and management of underestimated modifiable factors potentially contributing to morbidity

Ovarian cancer is the leading cause of gynaecological cancer deaths and the seventh most commonly diagnosed cancer among women worldwide, so that, as it is related to substantial and increasing disease burden, the management of ovarian cancer survivors should be a priority. Such issues involve prevention and management of emotional distress, anxiety/depressive symptoms, and maintenance of quality of life from initial diagnosis to post-treatment. Within this framework, sleep disturbances, in particular insomnia, are emerging as modifiable determinants of mental health, also contributing to substantial morbidity among cancer, including ovarian cancer. To this aim we conducted a systematic review according to PRISMA guidelines on prevalence and management of insomnia and circadian sleep disorders in ovarian cancer, while selecting 22 papers. Insomnia was evaluated in ovarian cancer and, while circadian sleep disturbances were poorly assessed in ovarian cancer, insomnia increased from 14% to 60% of patients. Insomnia was associated with cancer-related comorbid conditions such as emotional distress, anxiety/depressive symptoms and low quality of life. Despite this evidence, no studies have been conducted about insomnia treatment in ovarian cancer. The burden of insomnia and circadian sleep disorders in patients with ovarian cancer still needs to be addressed, and requires a call to action for the evaluation and management of these potential modifiable factors that might contribute to ovarian cancer morbidity.

Management of common clinical problems experienced by survivors of cancer

Improvements in early detection and treatment have led to a growing prevalence of survivors of cancer worldwide. Models of care fail to address adequately the breadth of physical, psychosocial, and supportive care needs of those who survive cancer. In this Series paper, we summarise the evidence around the management of common clinical problems experienced by survivors of adult cancers and how to cover these issues in a consultation. Reviewing the patient's history of cancer and treatments highlights potential long-term or late effects to consider, and recommended surveillance for recurrence. Physical consequences of specific treatments to identify include cardiac dysfunction, metabolic syndrome, lymphoedema, peripheral neuropathy, and osteoporosis. Immunotherapies can cause specific immune-related effects most commonly in the gastrointestinal tract, endocrine system, skin, and liver. Pain should be screened for and requires assessment of potential causes and non-pharmacological and pharmacological approaches to management. Common psychosocial issues, for which there are effective psychological therapies, include fear of recurrence, fatigue, altered sleep and cognition, and effects on sex and intimacy, finances, and employment. Review of lifestyle factors including smoking, obesity, and alcohol is necessary to reduce the risk of recurrence and second cancers. Exercise can improve quality of life and might improve cancer survival; it can also contribute to the management of fatigue, pain, metabolic syndrome, osteoporosis, and cognitive impairment. Using a supportive care screening tool, such as the Distress Thermometer, can identify specific areas of concern and help prioritise areas to cover in a consultation.

Prostate Cancer and Sleep Disorders: A Systematic Review

Simple Summary

Longer survival times for prostate cancer patients due to efficient treatments consisting of local radiotherapy, prostatectomy and androgen-deprivation therapy, as well as androgen-receptor-targeted agents, increases the importance of side effect management. Sleep disturbances are higher in this group than the general population and no clear mechanism(s) explains this. This systematic review finds a reported effect in 14 of 16 included studies on sleep quality changes for these patients. All reported treatments showed some kind of negative effect on sleep quality, including ADT. Limitations are discussed and recommendations made for progressing the understanding and then for mitigation strategies of these side effects.

Abstract

Prostate cancer (PCa) treatment involves multiple strategies depending on the disease’s stage. Androgen deprivation therapy (ADT) remains the gold standard for advanced and metastatic stages. Sleep quality has been suggested as being additionally influenced also by local radiotherapy, prostatectomy and androgen-receptor (AR)-targeted agents. We performed a systematic review exploring the landscape of studies published between 1 January 1990 and 31 July 2021, investigating sleep disturbances in PCa patients receiving active treatments, including the influence of hormonal therapy on sleep quality as a factor affecting their quality of life. Out of 45 articles identified, 16 studies were selected, which recruited patients with PCa, undergoing active treatment in either a prospective longitudinal or cross-sectional study. Development of sleep disorders or changes in sleep quality were reported in 14 out of 16 trials included. Only five trials included objective measurements such as actigraphy, mostly at one time point and without a baseline assessment. Limitations to be addressed are the small number of existing trials, lack of randomized trials and heterogeneity of methodologies used. This systematic review outlines the lack of prospective trials investigating sleep disorders, with a rigorous methodology, in homogeneous cohorts of PCa patients. Future trials are needed to clarify the prevalence and impact of this side effect of PCa treatments.

Quelle est la place des professionnels de santé dans l’adhésion aux programmes thérapeutiques en ligne de l’insomnie ? Éléments de réflexion issus de l’étude Sleep-4-All-1 et protocole de l’étude Sleep-4-All-2.0

La thérapie cognitivocomportementale de l’insomnie (TCC-I) demeure difficile d’accès pour les patients atteints de cancer. Sa digitalisation semble une solution prometteuse pour bénéficier au plus grand nombre. La faisabilité d’un programme TCC-I québécois a été démontrée en France, tout en révélant les limites d’un dispositif suivi en autonomie et à distance. L’enjeu reste de mieux comprendre le rôle des professionnels de santé dans l’accompagnement des patients dans ce type de programme. C’est l’objectif de l’étude Sleep-4-All-2.0 dont nous présenterons ici le protocole.

Modifiable factors associated with health-related quality of life among lung cancer survivors following curative intent therapy

OBJECTIVE

The number of lung cancer survivors is increasing along with advances in screening, diagnosis, and treatment. Following curative intent therapy, many lung cancer survivors experience significant health-related quality of life (HRQL) impairments. We sought to identify potentially modifiable factors that contribute to the HRQL of these patients.

MATERIALS AND METHODS

In this cross-sectional observational study of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy, we used a conceptual model to examine factors that included behavioral, objective functional and physiologic, self-rated function and symptom burden, specific comorbidities, and non-modifiable demographic and clinical lung cancer-related characteristics. We assessed HRQL using the valid and prognostic European Organization for Research and Treatment of Cancer Quality of Life (QoL) Core 30 global health/QoL subscale. We used univariable and multivariable linear regression modeling with backward elimination of potentially modifiable and non-modifiable factors, and interpreted clinically and statistically significant, consistent, and independent modifiable factors as meaningful.

RESULTS

Among 75 participants at a median of 12 months since treatment completion, the mean (standard deviation) C30 global health/QoL score was 62.7 (23.3) points (0-100 scale range). In multivariable analysis, with and without non-modifiable factors, we identified three clinically and statistically significant, consistent, and independent factors (unstandardized β range) associated with global health/QoL: 1) abnormal exercise-induced dyspnea (-9.23 to -10.0 points); 2) impaired self-rated role function (or inability to perform work or daily activities and pursuing leisure-time activities) (-12.6 to -16.4 points); and 3) abnormal insomnia (or trouble sleeping) (-12.6 to -16.4 points).

CONCLUSION

We identified meaningful modifiable factors associated with the HRQL of disease-free, stage I-IIIA lung cancer survivors following curative intent therapy. Interventions to improve the HRQL of these patients should aim to reduce exercise-induced dyspnea, improve role function - the ability to perform work and other daily including leisure-time activities, and control insomnia.