Sleep Disruption and Cancer: Chicken or the Egg?

Non-pharmacological interventions for sleep disturbance ("insomnia") in patients with advanced cancer: a scoping review

PURPOSE

Sleep disturbances are a common yet overlooked symptom in patients with advanced cancer. Pharmacological interventions have been widely used to manage sleep disturbances; however, concerns related to their adverse effects have resulted in a need for alternative interventions. The purpose of this scoping review is to appraise the published literature on the non-pharmacological management of sleep disturbances in patients with advanced cancer.

METHODS

This scoping review was completed using the recommended methodological framework. An extensive literature search was completed using five electronic databases (Medline, CINAHL, Embase, APA PsycINFO, CENTRAL) and the Cochrane library. There were no restrictions applied to the search in relation to the years published. Only studies published in the English language were included.

RESULTS

We identified 9 studies published between 2010 and 2023 which focused on non-pharmacological management of sleep disturbances in patients with advanced cancer. Specific interventions included cognitive behavioural therapy, mindfulness-based therapies, bright light therapy, sleep hygiene, and other non-standard interventions. Improvements in sleep disturbance were noted in all studies, but only some studies showed statistical significance.

CONCLUSION

This scoping review identified a relatively small number of relevant studies, involving a relatively small number of participants. Moreover, the studies involved very different interventions, with very different methodologies (including type/time of assessments). Thus, it is difficult to recommend any particular non-pharmacological intervention at this time. Nevertheless, non-pharmacological interventions undoubtedly have a role to play in the management of sleep disturbance in patients with advanced cancer.

Low blood orexin concentration as a predictor of increased nutritional risk and all-cause mortality after surgery for colorectal cancer

Introduction

Orexin regulates food intake, as well as the development and progression of neoplasms.

Aim

The aim of this study was to determine associations between nutritional risk and status and neoplasm stage and prognosis in patients who underwent surgery for colorectal cancer (CRC).

Material and methods

In 84 consecutive patients undergoing surgery for CRC, serum orexin, nutritional risk and body composition (assessed by bioelectrical impedance analysis and cross-sectional area determined using abdominal CT) were evaluated before the operation and 3 months after the surgery. The long-term follow-up lasted 1296.0 ±617.7 days.

Results

Compared to CRC patients with a serum orexin concentration lower than the cutoff value (197.9 pg/ml) determined in ROC curve analysis in prediction of all-cause mortality during long-term follow-up, those with orexin concentrations equal to or higher than the cutoff value were, at baseline and at the 3-month visit, more likely to have a lower score on the nutritional NRS2002 and a higher score on functional scales, greater handgrip strength, and higher skeletal muscle mass, and were less likely to suffer perioperative complications and all-cause mortality (OR = 0.34; 95% CI: 0.13-0.89; p = 0.026) during the follow-up period. No statistically significant differences in tumor size, histopathological grade or clinical stage were found between CRC patient groups divided according to orexin blood concentration.

Conclusions

Serum orexin concentrations were found to be statistically significantly associated with patients' nutritional risk and status before surgery and at a 3-month follow-up visit, and with all-cause mortality during the 3.6-year follow-up.

Effects of chronic diseases on health related quality of life is mediated by sleep difficulty in middle aged and older adults

Middle-aged and older adults with chronic diseases are more likely to encounter sleep difficulty and have a reduced Health-Related Quality of Life (HRQoL), but there is little research on their possible mechanisms. Therefore, the main objective of this study was to explore how sleep difficulty mediates the impact of chronic diseases on the HRQoL of middle-aged and older adults. The survey data were from a cross-sectional study carried out in 2019 in Hangzhou, China. We used a multi-stage cluster random sampling method to recruit participants from seven districts in Hangzhou. Multiple regression was used to analyze the relationship between chronic diseases, sleep difficulty and HRQoL. And the mediate package in the R language was used to analyze the mediating effect. A total of 3,550 middle-aged and older adults were enrolled, including 2,273 patients with chronic diseases and 1,277 patients without them. Patients with chronic diseases had lower health utility values (β=-0.0084, P < 0.01) and were more likely to suffer from sleep difficulty (β = 0.5737, P < 0.001). After correcting for demographic and life characteristics, the mediation analysis results indicated that sleep difficulty mediated the relationship between chronic diseases and HRQoL (β=-0.0022, 95% Bca CI: -0.0034 -0.0014). Additionally, sleep difficulty influenced the association between chronic diseases and daily activities as well as pain (or discomfort) (β = 0.0083, 95% Bca CI: 0.0042-0.0111; β = 0.0162, 95% Bca CI: 0.0107-0.0225) in the analysis of the dimensions. Sleep difficulty partially mediated the relationship between chronic diseases and HRQoL, and primarily in the daily activities and pain (or discomfort) dimensions in middle-aged and older adults.

Indoor and outdoor artificial light-at-night (ALAN) and cancer risk: A systematic review and meta-analysis of multiple cancer sites and with a critical appraisal of exposure assessment

Exposure to artificial light-at-night (ALAN) has been linked to cancer risk. Few meta-analyses on this topic have reviewed only breast cancer. This study aimed to systematically review and meta-analyze existing studies on ALAN exposure and cancer incidence, thoroughly evaluating exposure assessment quality. We considered observational studies (cohort, case-control, cross-sectional) on ALAN exposure (indoor and outdoor) and cancer incidence, measured by relative risk, hazard ratio, and odds ratio. We searched six databases, two registries, and Google Scholar from inception until April 17, 2024. Quality of studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. Random-effects meta-analysis was used to estimate relative risks (RR) and 95 % confidence intervals (CI) for ALAN exposures. We identified 9835 studies and included 28 for qualitative synthesis with 2,508,807 individuals (15 cohort, 13 case-control). Out of the included studies, 20 studies on breast cancer (731,493 individuals) and 2 studies on prostate cancer (53,254 individuals) were used for quantitative synthesis. Higher levels of outdoor ALAN were associated with breast cancer risk (meta-estimate = 1.12, 95 % CI 1.03-1.23 (I2 = 69 %)). We observed a non-significant positive association between indoor ALAN levels and breast cancer risk (meta-estimate = 1.07, 0.95-1.21, I2 = 60 %), and no differences by menopausal status. The meta-analysis for prostate cancer suggested a non-statistically significant increased risk for higher levels of outdoor ALAN (meta-estimate = 1.43, 0.75-2.72, I2 = 90 %). In the qualitative synthesis, we observed positive associations with non-Hodgkin lymphoma and colorectal, pancreatic and thyroid cancer. We found an association between outdoor ALAN and breast cancer risk. However, most studies relied on satellite-images with a very low resolution (1 to 5 km, from the Defense Meteorological Program [DMSP]) and without information on color of light. Future studies with better exposure assessment should focus on investigating other cancer sites.

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.

The network structures of depressive and insomnia symptoms among cancer patients using propensity score matching: Findings from the Health and Retirement Study (HRS)

OBJECTIVE

Both depression and insomnia are found to be more prevalent in cancer patients compared to the general population. This study compared the network structures of depression and insomnia among cancer patients versus cancer-free participants (controls hereafter).

METHOD

The 8-item Center for Epidemiological Studies Depression Scale (CESD-8) and the 4-item Jenkins Sleep Scale (JSS-4) were used to measure depressive and insomnia symptoms, respectively. Propensity score matching (PSM) was used to construct the control group using data from the Health and Retirement Study (HRS). In total, a sample consisting of 2216 cancer patients and 2216 controls was constructed. Central (influential) and bridge symptoms were estimated using the expected influence (EI) and bridge expected influence (bridge EI), respectively. Network stability was assessed using the case-dropping bootstrap method.

RESULT

The prevalence of depression (CESD-8 total score ≥ 4) in cancer patients was significantly higher compared to the control group (28.56 % vs. 24.73 %; P = 0.004). Cancer patients also had more severe depressive symptoms relative to controls, but there was no significant group difference for insomnia symptoms. The network structures of depressive and insomnia symptoms were comparable between cancer patients and controls. "Felt sadness" (EI: 6.866 in cancer patients; EI: 5.861 in controls), "Felt unhappy" (EI: 6.371 in cancer patients; EI: 5.720 in controls) and "Felt depressed" (EI: 6.003 in cancer patients; EI: 5.880 in controls) emerged as the key central symptoms, and "Felt tired in morning" (bridge EI: 1.870 in cancer patients; EI: 1.266 in controls) and "Everything was an effort" (bridge EI: 1.046 in cancer patients; EI: 0.921 in controls) were the key bridge symptoms across both groups.

CONCLUSION

Although cancer patients had more frequent and severe depressive symptoms compared to controls, no significant difference was observed in the network structure or strength of the depressive and insomnia symptoms. Consequently, psychosocial interventions for treating depression and insomnia in the general population could be equally applicable for cancer patients who experience depression and insomnia.

Melatonin Inhibits Chemical Carcinogen-mediated Malignant Transformation of Urothelial Cells: In Vitro Evidence

BACKGROUND/AIM

The efficacy of melatonin and its biological significance in human bladder cancer remain poorly understood. This study aimed to investigate the functional role of melatonin in urothelial carcinogenesis.

MATERIALS AND METHODS

In human normal urothelial SVHUC cells with exposure to the chemical carcinogen 3-methylcholanthrene, we assessed the effects of melatonin on the neoplastic/malignant transformation.

RESULTS

In the in vitro system with carcinogen challenge, melatonin significantly prevented the neoplastic transformation of SV-HUC-1 cells. In addition, melatonin treatment resulted in increased expression of SIRT1, Rb1, and E-cadherin, and decreased expression of N-cadherin and FGFR3 in SV-HUC-1 cells. Furthermore, publicly available datasets from GSE3167 revealed that the expression of melatonin receptor 1 and melatonin receptor 2 was significantly down-regulated in bladder urothelial carcinoma tissues, compared with adjacent normal urothelial tissues.

CONCLUSION

These findings indicate that melatonin serves as a suppressor for urothelial tumorigenesis. To the best of our knowledge, this is the first preclinical study demonstrating the impact of melatonin on the development of urothelial cancer.

Impact of sleep on gastrointestinal cancer

Sleep problems have become a significant public health concern, affecting a large portion of the global population and have been linked to increased morbidity and mortality. The incidence of gastrointestinal (GI) cancers continues to rise, posing a substantial burden on healthcare systems worldwide. This editorial aims to delve into the impact of sleep on GI cancers, including esophageal, gastric, colorectal, hepatobiliary, and pancreatic cancer. Recent literature investigating the potential connections between GI cancers and sleep was reviewed. We considered aspects such as sleep duration, sleep disorders, and circadian rhythmicity, in order to explore the underlying mechanisms that can contribute to the development of GI cancers and propose avenues for future research.

Impact of insomnia on ovarian cancer risk and survival: a Mendelian randomization study

BACKGROUND

Insomnia is the most common sleep disorder in patients with epithelial ovarian cancer (EOC). We investigated the causal association between genetically predicted insomnia and EOC risk and survival through a two-sample Mendelian randomization (MR) study.

METHODS

Insomnia was proxied using genetic variants identified in a genome-wide association study (GWAS) meta-analysis of UK Biobank and 23andMe. Using genetic associations with EOC risk and overall survival from the Ovarian Cancer Association Consortium (OCAC) GWAS in 66,450 women (over 11,000 cases with clinical follow-up), we performed Iterative Mendelian Randomization and Pleiotropy (IMRP) analysis followed by a set of sensitivity analyses. Genetic associations with survival and response to treatment in ovarian cancer study of The Cancer Genome Atlas (TCGA) were estimated controlling for chemotherapy and clinical factors.

FINDINGS

Insomnia was associated with higher risk of endometrioid EOC (OR = 1.60, 95% CI 1.05-2.45) and lower risk of high-grade serous EOC (HGSOC) and clear cell EOC (OR = 0.79 and 0.48, 95% CI 0.63-1.00 and 0.27-0.86, respectively). In survival analysis, insomnia was associated with shorter survival of invasive EOC (OR = 1.45, 95% CI 1.13-1.87) and HGSOC (OR = 1.4, 95% CI 1.04-1.89), which was attenuated after adjustment for body mass index and reproductive age. Insomnia was associated with reduced survival in TCGA HGSOC cases who received standard chemotherapy (OR = 2.48, 95% CI 1.13-5.42), but was attenuated after adjustment for clinical factors.

INTERPRETATION

This study supports the impact of insomnia on EOC risk and survival, suggesting treatments targeting insomnia could be pivotal for prevention and improving patient survival.

FUNDING

National Institutes of Health, National Cancer Institute. Full funding details are provided in acknowledgments.

Mechanism of Action of Melatonin as a Potential Adjuvant Therapy in Inflammatory Bowel Disease and Colorectal Cancer

Inflammatory bowel disease (IBD), a continuum of chronic inflammatory diseases, is tightly associated with immune system dysregulation and dysbiosis, leading to inflammation in the gastrointestinal tract (GIT) and multiple extraintestinal manifestations. The pathogenesis of IBD is not completely elucidated. However, it is associated with an increased risk of colorectal cancer (CRC), which is one of the most common gastrointestinal malignancies. In both IBD and CRC, a complex interplay occurs between the immune system and gut microbiota (GM), leading to the alteration in GM composition. Melatonin, a neuroendocrine hormone, was found to be involved with this interplay, especially since it is present in high amounts in the gut, leading to some protective effects. Actually, melatonin enhances the integrity of the intestinal mucosal barrier, regulates the immune response, alleviates inflammation, and attenuates oxidative stress. Thereby, the authors summarize the multifactorial interaction of melatonin with IBD and with CRC, focusing on new findings related to the mechanisms of action of this hormone, in addition to its documented positive outcomes on the treatment of these two pathologies and possible future perspectives to use melatonin as an adjuvant therapy.

Investigation of Common Pathways and Putative Biomarker Candidates of Colorectal Cancer and Insomnia by Using Integrative In-Silico Approaches

Background

Colorectal cancer (CRC) is one of the leading causes of cancer-related mortalities across the globe. Accumulating evidence shows that individuals having sleep disorders such as insomnia are at high risk of developing CRC, yet the association of sleep disorders with CRC risk is still unclear. Here, we investigated the potential molecular connections between CRC and insomnia using integrative in silico approaches.

Objective

This study aims to explore the potential molecular connections between CRC and insomnia utilizing integrative in-silico methodologies.

Methods and Methods

Gene expression microarray datasets for CRC and insomnia samples were retrieved from the NCBI-GEO database and analyzed using R. Functional enrichment analysis of common differentially expressed genes (DEGs) was performed by the g: Profiler tool. Cytoscape software was used to construct a protein-protein interaction network and hub gene identification. Expression profiles of hub genes in TCGA datasets were also determined, and predicted miRNAs targeting hub genes were analyzed by miRNA target prediction tools.

Results

Our results revealed a total of 113 shared DEGs between the CRC and insomnia datasets. Six genes (HSP8A, GAPDH, HSP90AA1, EEF1G, RPS6, and RPLP0), which were also differently expressed in TCGA datasets, were prioritized as hub genes and were found to be enriched in pathways related to protein synthesis. hsa-miR-324-3p, hsa-miR-769-3p, and hsa-miR-16-5p were identified as promising miRNA biomarkers for two diseases.

Conclusions

Our in-silico analysis provides promising evidence of the molecular link between CRC and insomnia and highlights multiple potential molecular biomarkers and pathways. Validation of the results by wet lab work can be utilized for novel translational and precision medicine applications to alleviate the public health burden of CRC.

The Drosophila blood-brain barrier regulates sleep via Moody G protein-coupled receptor signaling

Sleep is vital for most animals, yet its mechanism and function remain unclear. We found that permeability of the BBB (blood-brain barrier)-the organ required for the maintenance of homeostatic levels of nutrients, ions, and other molecules in the brain-is modulated by sleep deprivation (SD) and can cell-autonomously effect sleep changes. We observed increased BBB permeability in known sleep mutants as well as in acutely sleep-deprived animals. In addition to molecular tracers, SD-induced BBB changes also increased the penetration of drugs used in the treatment of brain pathologies. After chronic/genetic or acute SD, rebound sleep or administration of the sleeping aid gaboxadol normalized BBB permeability, showing that SD effects on the BBB are reversible. Along with BBB permeability, RNA levels of the BBB master regulator moody are modulated by sleep. Conversely, altering BBB permeability alone through glia-specific modulation of moody, gαo, loco, lachesin, or neuroglian-each a well-studied regulator of BBB function-was sufficient to induce robust sleep phenotypes. These studies demonstrate a tight link between BBB permeability and sleep and indicate a unique role for the BBB in the regulation of sleep.

Sleep Duration and Stress Level in the Risk of Gastric Cancer: A Pooled Analysis of Case-Control Studies in the Stomach Cancer Pooling (StoP) Project

The association between sleep and stress and cancer is underinvestigated. We evaluated these factors in association with gastric cancer (GC). Five case-control studies from the Stomach Cancer Pooling (StoP) Project were included. We calculated the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for sleep duration and stress level in association with GC through multiple logistic regression models adjusted for several lifestyle factors. The analysis included 1293 cases and 4439 controls, 215 cardia and 919 noncardia GC, and 353 diffuse and 619 intestinal types. Sleep duration of ≥9 h was associated with GC (OR =1.57, 95% CI = 1.23-2.00) compared to 8 h. This was confirmed when stratifying by subsite (noncardia OR = 1.59, 95% CI = 1.22-2.08, and cardia OR = 1.63, 95% CI = 0.97-2.72) and histological type (diffuse OR = 1.65, 95% CI = 1.14-2.40 and intestinal OR = 1.24, 95% CI = 0.91-1.67). Stress was associated with GC (OR = 1.33, 95% CI = 1.18-1.50, continuous). This relationship was selectively related to noncardia GC (OR = 1.28, 95% 1.12-1.46, continuous). The risk of diffuse (OR = 1.32, 95% CI = 1.11-1.58) and intestinal type (OR = 1.23, 95% CI = 1.07-1.42) were higher when stress was reported. Results for the association between increasing level of stress and GC were heterogeneous by smoking and socioeconomic status (p for heterogeneity = 0.02 and <0.001, respectively). In conclusion, long sleep duration (≥9 h) was associated with GC and its subtype categories. Stress linearly increased the risk of GC and was related to noncardia GC.

Identification of distinct symptom profiles in patients with gynecologic cancers using a pre-specified symptom cluster

PURPOSE

Pain, fatigue, sleep disturbance, and depression are four of the most common symptoms in patients with gynecologic cancer. The purposes were to identify subgroups of patients with distinct co-occurring pain, fatigue, sleep disturbance, and depression profiles (i.e., pre-specified symptom cluster) in a sample of patients with gynecologic cancer receiving chemotherapy and assess for differences in demographic and clinical characteristics, as well as the severity of other common symptoms and QOL outcomes among these subgroups.

METHODS

Patients completed symptom questionnaires prior to their second or third cycle of chemotherapy. Latent profile analysis was used to identify subgroups of patients using the pre-specified symptom cluster. Parametric and nonparametric tests were used to evaluate for differences between the subgroups.

RESULTS

In the sample of 233 patients, two distinct latent classes were identified (i.e., low (64.8%) and high (35.2%)) indicating lower and higher levels of symptom burden. Patients in high class were younger, had child care responsibilities, were unemployed, and had a lower annual income. In addition, these women had a higher body mass index, a higher comorbidity burden, and a lower functional status. Patients in the high class reported higher levels of anxiety, as well as lower levels of energy and cognitive function and poorer quality of life scores.

CONCLUSIONS

This study identified a number of modifiable and non-modifiable risk factors associated with membership in the high class. Clinicians can use this information to refer patients to dieticians and physical therapists for tailored interventions.

Global research on cancer and sleep: A bibliometric and visual analysis of the last two decades

Objective

The study aimed to analyze the research status, hotspots, and frontiers of global research on cancer and sleep through bibliometrics and provide references and guidance for future research.

Methods

The literature regarding cancer and sleep from 2002 to 2022 was searched from the Web of Science Core Collection (WoSCC) database. CiteSpace 5.6.R3 was performed for visualization analysis.

Results

A total of 1,172 publications were identified. The number of publications in the field has gradually increased over the past two decades. The United States had the most prominent contributions. Taipei Medical University and the University of California, San Francisco, and David Gozal were the most prolific institutions and author, respectively. The most published academic journal was Supportive Care in Cancer. The research hotspots can be summarized into the symptom cluster intervention for cancer survivors and the association between cancer and melatonin and/or obstructive sleep apnea (OSA). The complex interaction between cancer and sleep disruption and the influencing factors of sleep quality may be the emerging trends of research.

Conclusion

This study systematically analyzed the hotspots and frontiers in the field of cancer and sleep and called for strengthening cooperation among countries, institutions, and authors. In addition, intervention measures for the cancer symptom cluster, the bioavailability of exogenous melatonin, the causal relationship between OSA and cancer, the mechanism of tumor-induced sleep disruption, the dose–response relationship between sleep duration and cancer risk, and the path relationship between sleep quality influencing factors may be the focus of future research.

Risk-Reducing Measures for Cancer Prevention

Cancer, or malignancy, continues to be one of the most serious health problems in the world, leading to death and disability. Unlike in previous years, where new cases of cancer were predominant in developed nations, the number of cases of cancer and the resultant deaths are increasing in low- and middle-income countries. This is partially attributable to the current trend of adopting a Western lifestyle, substantial urbanization, and the rise in infections, such as the human papillomavirus (HPV) and hepatitis B virus (HBV), which together account for over 30% of cancer cases in underdeveloped and developing nations. The deleterious impact of cancer, as cases multiply worldwide, is multi-dimensional. Cancer exerts serious physical, psychological, and monetary burdens, not only on cancer patients but also on their family members, close friends, health care systems, and society at large. Importantly, over half of all cancer types can be prevented globally by mitigating the risk and causative factors as well as prompt adherence to scientifically recommended prevention measures. This review provides various scientifically based and people-centered strategies that every individual could adopt to reduce their risk of developing cancer in the future. It is recommended that, for these cancer prevention strategies to be effective, there should be a strong political will from the governments of individual countries to enact specific laws and implement policies that will significantly reduce sedentary lifestyles and unhealthy eating among the general public. Likewise, HPV and HBV vaccines, as well as cancer screenings, should be made available, affordable, and accessible on a timely basis for those who are eligible to take them. Finally, intensified campaigns and numerous informative and educational programs that promote cancer prevention should be initiated globally.

Sleep disturbance is associated with perturbations in immune-inflammatory pathways in oncology outpatients undergoing chemotherapy

OBJECTIVE/BACKGROUND

Sleep disturbance is a common problem in patients receiving chemotherapy. Purpose was to evaluate for perturbations in immune-inflammatory pathways between oncology patients with low versus very high levels of sleep disturbance.

PATIENTS/METHODS

Sleep disturbance was evaluated using the General Sleep Disturbance Scale six times over two cycles of chemotherapy. Latent profile analysis was used to identify subgroups of patients with distinct sleep disturbance profiles. Pathway impact analyses were performed in two independent samples using gene expression data obtained from RNA sequencing (n = 198) and microarray (n = 162) technologies. Fisher's combined probability test was used to identify significantly perturbed pathways between Low versus Very High sleep disturbance classes.

RESULTS

In the RNA sequencing and microarray samples, 59.1% and 51.9% of patients were in the Very High sleep disturbance class, respectively. Thirteen perturbed pathways were related to immune-inflammatory mechanisms (i.e., endocytosis, phagosome, antigen processing and presentation, natural killer cell mediated cytotoxicity, cytokine-cytokine receptor interaction, apoptosis, neutrophil extracellular trap formation, nucleotide-binding and oligomerization domain-like receptor signaling, Th17 cell differentiation, intestinal immune network for immunoglobulin A production, T-cell receptor signaling, complement and coagulation cascades, and tumor necrosis factor signaling).

CONCLUSIONS

First study to identify perturbations in immune-inflammatory pathways associated with very high levels of sleep disturbance in oncology outpatients. Findings suggest that complex immune-inflammatory interactions underlie sleep disturbance.

Integrative Approaches to the Treatment of Cancer

A significant proportion of cancer patients use forms of complementary medicine or therapies. An integrative approach to cancer management combines conventional medicine with evidence-based complementary medicines/therapies and lifestyle interventions, for the treatment and prevention of disease and the optimisation of health. Its basis is a holistic one; to treat the whole person, not just the disease. It makes use of adjunct technologies which may assist the clinician in diagnosis of early carcinogenesis and monitoring of treatment effectiveness. Many factors contribute to the development of cancer including some which are largely modifiable by the patient and which oncologists may be in a position to advise on, such as stress, poor nutrition, lack of physical activity, poor sleep, and Vitamin D deficiency. An integrative approach to addressing these factors may contribute to better overall health of the patient and better outcomes. Evidence-based complementary medicine approaches include the use of supplements, herbal medicine, various practices that reduce stress, and physical therapies. Individualised to the patient, these can also help address the symptoms and signs associated with cancer and its orthodox treatment.