Sleep disorders among cancer survivors: A ‘massive issue’ with long-term implications
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Key takeaways:
- The prevalence of sleep disorders in cancer survivors is not completely understood.
- Nonpharmacologic approaches such as cognitive behavioral therapy and exercise are often recommended for these disorders.
Sleep disorders are among the biggest issues patients with cancer and survivors face, yet research on interventions to address these disorders remains sparse, according to speakers at National Comprehensive Cancer Network Annual Conference.
“A study out of Finland published about 2 years ago looked at a group of survivors and compared them [with] age-matched individuals without cancer in the general population,” Eric S. Zhou, PhD, a faculty member in the division of sleep medicine and assistant professor of pediatrics at Harvard Medical School who serves as a member of the NCCN Cancer-Related Fatigue Panel, said during a plenary session at the conference. “They found that sleep was worse in cancer survivors across all age groups and across several domains of quality of life compared [with] the general population. It is a massive issue.”
A challenge to quantify
Sleep disorders vary widely among individual cancer survivors, according to Zhou.
“This might sound obvious, but bad sleep is more than just bad sleep,” Zhou said. “If you look at the International Classification of Sleep Disorders, there’s a total of 83 different disorders a person can have.”
The classification includes seven categories of sleep disorders: insomnia, sleep-related breathing disorders, central disorders of hypersomnolence, circadian rhythm sleep/wake disorders, parasomnias sleep-related movement disorders and “other sleep disorders.” A recent review could not conclusively determine how many patients with cancer and survivors experience these disorders, according to Zhou.
“This means we really don’t have a clue how many of our patients and survivors really have diagnosable sleep disorders,” he said.
Insomnia most common
Insomnia, the most common sleep disorder presented in the oncology setting, is not limited to patients undergoing active treatment, according to Zhou. A study conducted in Quebec that followed patients with cancer after surgical treatment showed insomnia can persist well into survivorship.
“At baseline, when folks are just diagnosed with disease and need to be treated, we expect bad sleep to be common,” Zhou said. “However, a year and a half out, more than a quarter of these patients were still meeting diagnostic criteria for a disorder that we tend to think of as something that should self-resolve over time. It doesn’t.”
Better sleep may not only improve quality of life for patients with cancer and survivors, but also survival outcomes.
In a study conducted at Stanford University, researchers tracked the sleep patterns of patients with advanced breast cancer. Results showed an improvement in sleep efficiency by just 10% among those categorized as poor sleepers could potentially lead to a 32% increase in survival.
“If Pfizer figured out how to bottle that, their shareholders would be ecstatic,” he said. “A 32% increase in survival is amazing.”
NCCN survivorship guidelines and those of several professional organizations recommend cognitive behavioral therapy (CBT) — not a medication —as first-line treatment for insomnia, Zhou said.
“CBT is the first thing we should be giving to our patients,” he said.
The two main components of CBT for sleep disorders are stimulus control and sleep restriction, according to Zhou.
“Sleep restriction simply gets to the heart of insomnia, which is that patients are lying in bed trying to get more sleep rather than good-quality sleep,” he said. “Stimulus control gets to the idea that patients who have insomnia try really hard to sleep, and that results in their inability to fall asleep.”
Zhou and colleagues conducted a survey study that indicated there is room for improvement in the way cancer centers treat insomnia among patients with cancer and survivors.
The researchers surveyed adult survivorship program directors at 25 well-resourced NCI-designated comprehensive cancer centers that were also NCCN member institutions.
“One standout finding was that these respondents felt that only a small percentage of these survivors were getting good insomnia treatment,” Zhou said. “No one beat 50%.”
The findings suggest a need for improved automated screening tools, sleep disorder programs embedded within cancer centers and physician training in sleep disorders, Zhou said.
“We surveyed psychologists like myself and found that over 90% did not have a single moment of training in their graduate programs about sleep,” he said. “Disturbingly, over 50% said they weren’t really confident to treat sleep disorders. So, there’s a mismatch and a real issue here.”
Cancer-related fatigue
A descriptive study by Momayyzi and colleagues, published in Journal of Caring Sciences, showed a significant relationship between sleep quality and fatigue among patients with cancer, nearly 70% of whom reported poor sleep quality.
Both patients undergoing active cancer treatment and survivors frequently cite fatigue as one of their most distressing symptoms, even above pain and nausea, according to Kristin Dickinson, PhD, RN, OCN, assistant professor of nursing at the University of Nebraska Medical Center College of Nursing.
“Patients are often able to take medications that control those symptoms, unlike with fatigue. We are still learning a lot about what we can do to manage this symptom.”
Prevalence of fatigue among patients with cancer and survivors varies based on the type of cancer, comorbidities and lifestyle habits, Dickinson said, adding that it affects up to 90% of patients in active treatment.
“Unfortunately, fatigue doesn’t stop when treatment stops, and it doesn’t stop when the disease is in remission,” Dickinson said. “We can have up to 50% of patients still reporting fatigue in long-term survivorship.”
That percentage may be even higher, as cancer-associated fatigue is often underreported, underdiagnosed and undertreated, Dickinson said.
“A shocking statistic that I read recently was that 80% of survivors felt nothing could be done for their fatigue, so why report it?” she said. “Providers were hesitant to ask about patient fatigue for many of the same reasons: they weren’t sure how to assess it and they weren’t sure how to manage it in terms of quality of life.”
For patients on active treatment, NCCN guidelines recommend nonpharmacologic treatment strategies as a first-line approach for managing cancer-related fatigue, Dickinson said. Physical activity is considered the best evidence-based strategy, she added.
For those who have completed treatment, approaches such as massage therapy and certain psychosocial interventions such as CBT are recommended in addition to exercise.
Resources for cancer survivors include American College of Sports Medicine’s evidence-based guidelines for cancer-related fatigue, Livestrong’s free or low-cost programs at certain YMCA locations, and Maple Tree Cancer Alliance’s in-person or virtual exercise guidance, Dickinson said. There are also patient exercise apps, such as one she created with colleague Anna L. Schwartz, PhD.
“Physical activity is one of the best evidence-based strategies for managing fatigue in cancer survivors,” Dickinson said. “Cancer fatigue and cancer fatigue relief is an individualized experience and requires individualized management.”
Cognitive impairment
Studies have supported similar interventions to improve cognitive function among patients with cancer and survivors.
Halle Moore, MD, director of breast medical oncology in the department of hematology and oncology at Cleveland Clinic Taussig Cancer Institute and member of the NCCN Survivorship Panel, discussed various forms of cognitive impairment cancer survivors might experience.
“Oftentimes, we will see difficulties with attention and multitasking, difficulties with word-finding, and a just a general need for more reminders,” Moore said. “Sometimes these concerns can be severe enough to affect performance at work. These symptoms can make an individual feel very isolated, although this is a common concern.”
Individuals who are older and those with comorbidities such as diabetes or cardiovascular disease are particularly susceptible to cognitive impairments, Moore said. Certain genetic factors, as well as hormonal changes induced by treatments, may also increase risk for cognitive impairment.
Currently, patient self-reporting is the primary way to evaluate cognitive changes in cancer survivors. Although formal neuropsychological testing may be warranted in some cases, especially when a clinician suspects a disability that may require disability benefits, these tests should be used selectively, Moore said.
When managing cancer-related cognitive impairment, clinicians should assess the patient’s medications, supplements, alcohol or substance use, medical comorbidities such as hypothyroidism, vitamin deficiencies, and untreated depression or anxiety.
“We need to address these modifiable factors and implement some of our suggestions for sleep and fatigue,” she said. “Like with fatigue, exercise and physical activity may improve cognitive reserve.”
Moore also suggested directing patients to a high-quality program offering cognitive rehabilitation.
“These may be at your institutions and you might not even know about them,” she said. “Often, they are found in the occupational or speech therapy departments — or in some centers, the neuropsychology department.”
For patients whose symptoms persist, Moore recommended referral to a specialized memory clinic. CBT may also benefit these patients.
NCCN guidelines allow for a trial of a psychostimulant, such as methylphenidate, for patients who do not respond to other approaches.
“Cancer-related cognitive impairment is common, but it’s generally not progressive, and most often does improve with time,” Moore said. “However, some certainly do experience long-term concerns. Management currently includes cognitive rehabilitation and addressing modifiable contributors.”
References:
- Better sleep predicts longer survival time for women with advanced breast cancer (press release). Available at: aasm.org/better-sleep-predicts-longer-survival-time-for-women-with-advanced-breast-cancer/. Published May 2, 2014. Accessed April 13, 2023.
- Momayyezi M, et al. J Caring Sci. 2021;doi:10.34172/jcs.2021.021.
- Mustian KM, et al. Oncol Hematol Rev. 2012;doi:10.17925/ohr.2012.08.2.81.
- Otte JL, et al. Cancer Med. 2015;doi:10.1002/cam4.356.
- Plenary session: Sleep disorders, fatigue and cognitive function in cancer survivors. Presented at: National Comprehensive Cancer Network 2023 Annual Meeting, March 31-April 2, Orlando.
- Roine E, et al. Breast. 2021;doi:10.1016/j.breast.2021.06.012.
- Zhou ES, et al. J Cancer Surviv. 2017;doi:10.1007/s11764-016.0564-1.
- Zhou ES, et al. Behav Sleep Med. 2021;doi:10.1080/15402002.2020.1860990.
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