Comparison of Differences and Determinants Between Presence and Absence of Sleep Disturbance in Hepatocellular Carcinoma Patients

Tsung-Lan Chu, MS, RN; Wen-Pin Yu; MS, RN; Shu-Ching Chen, PhD, RN; Hsi-Ling Peng, PhD(c), RN; Ming-Ju Wu, MS, RN


Cancer Nurs. 2011;34(5):354-360. 

In This Article

Abstract and Introduction


Background: Hepatocellular carcinoma patients often experience sleep disturbance after undergoing transcatheter arterial chemoembolization (TACE).
Objective: The objectives of this study were to (1) examine and compare symptom distress, depression, and sleep quality in hepatocellular carcinoma patients undergoing TACE with sleep disturbance versus without sleep disturbance and (2) examine the determinants of sleep disturbance in these patients.
Methods: Hepatocellular carcinoma patients undergoing TACE were recruited. The patients were evaluated 1 week (T1) and 1 month (T2) after receiving TACE in terms of performance status, symptom distress, depression (T1), and sleep disturbance (T2). Logistic regression was used to determine the predictive factors of sleep disturbance.
Results: Patients with sleep disturbance reported significantly higher overall symptom distress and depression and lower sleep quality than patients without sleep disturbance. The 5 leading causes of symptom distress in both groups were fatigue, pain, poor appetite, chest tightness, and fever. Older age, greater symptom distress, and higher levels of depression were significantly associated with sleep disturbance.
Conclusions: The results of this study show significant associations among symptom distress, depression at baseline, and sleep problems 1 month after undergoing TACE. Clinicians should be aware of the possibility of lasting sleep disturbance in hepatocellular carcinoma patients undergoing TACE.
Implications for Practice: In clinical care, symptom management, psychological consultation, and relaxation training may promote sleep quality.


Hepatocellular carcinoma, also known as primary malignancy of the hepatocyte, is a major cause of cancer-related mortality worldwide.[1] In the United States, approximately 18 160 new cases are reported annually.[2] In Taiwan, hepatocellular carcinoma has become the most common form of cancer and the leading cause of cancer death in males, as well as the third most common form of cancer and the third leading cause of cancer mortality among females.[3] Transcatheter arterial chemoembolization (TACE) is widely used to treat unresectable hepatocellular carcinoma.[4] Although the treatment outcomes are promising, the disease process and treatment may lead to varying levels of physical and psychological disturbance.[5–8] In addition, the transition from active to follow-up treatment may generate stress[8,9] and cause sleep problems for patients.

Sleep disturbance is a common problem among cancer patients, with a prevalence of approximately 30% to 50%.[10] Sleep disturbance is reported to be a significant problem for patients across the cancer care trajectory, including the treatment phase.[10] Several recent studies have reported the possibility of insomnia in people undergoing treatment for hepatocellular carcinoma.[5,6,11] Bianchi et al[5] reported that patients receiving treatment for hepatocellular carcinoma experienced greater sleep problems than cirrhosis patients, and sleep problems were strongly associated with poor health-related quality of life. Wible et al[8] also suggested that the perceived vitality of patients with hepatocellular carcinoma is likely to worsen after the first chemoembolization treatment. Sleep disturbance can cause various problems, including daytime sleepiness and cognitive dysfunction,[12] reduced ability to cope with stress, and interference with usual activities.[9]

Sleep disturbance is any condition that interferes with sleep and affects sleep quality. Sleep quality comprises 2 domains: an objective or quantitative domain (sleep duration, sleep latency, and number of arousals) and a subjective domain (depth or restfulness of sleep).[13] Evaluating sleep disturbance requires study participants to reflect on the previous month and describe their sleep experiences and daytime energy levels during this period.[13] The determinants of sleep disturbance may be multidimensional. In cancer patients, sleep may be disturbed by cancer disease, cancer-related stress, cancer treatment, treatment-related symptoms, and personal factors.[14,15] Previous studies have demonstrated that approximately 30% of people older than 65 years report problems indicating insomnia.[15] Akechi et al[14] found that age was a significant predictor of sleep disturbance in cancer patients, with younger patients more likely to be affected. Many cancer-related symptoms can cause sleep disturbance.[15] Hugel et al[16] reported that uncontrolled symptoms were the most common cause of sleep disturbance, reported by 60% of patients. Previous studies have revealed an association between sleep problems and physical functioning,[5] pain,[5] emotional reactions,[5,6] and fatigue[6,7,17] in patients with hepatocellular carcinoma. Hepatocellular carcinoma patients undergoing treatment often experience multiple symptoms, including fatigue,[6,11,17] pain,[11] weight loss,[11] and poor appetite.[11] These symptoms may persist after the completion of treatment. Symptom distress refers to perceived changes in functioning of the affected body part, which are subjective and private.[18,19] Symptom occurrence is the patient's recognition of the symptom's presence and can be assessed in terms of frequency, duration, and severity.[19] In addition, depression has been reported to be a frequent problem in patients with hepatocellular carcinoma.[20] Depression is also a major determinant of sleep problems in cancer patients. Depression is characterized by depressed mood, loss of interest or pleasure, feelings of guilt, disturbed sleep or appetite, low energy, and poor concentration.[21] Untreated depression has been associated with early awakening, difficulty returning to sleep, and nightmares.[16] A recent study revealed that hepatocellular carcinoma patients with higher levels of depression were more likely to experience sleep disturbance.[6]

The conceptual framework of this study was based on a literature review. We assumed that age could be a predictor of sleep disturbance.[14,15] Patients with greater symptom distress,[16] lower physical performance,[5] and higher levels of depression[16] were assumed to have strong probabilities of having sleep disturbance. In addition, we assumed that there were differences in symptoms, depression, and sleep quality between hepatocellular carcinoma patients undergoing TACE with and without sleep disturbance. Although many studies have investigated sleep disturbance in cancer patients, only a few of them have focused on patients with hepatocellular carcinoma.[6] Therefore, the aim of this study was to examine and compare symptom distress, depression, and sleep quality in hepatocellular carcinoma patients undergoing TACE with and without sleep disturbance, as well as examine determinants of sleep disturbance in these patients.


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