Insomnia in Cancer Patients: Interventions That May Help

Liam Davenport

May 18, 2018

Cancer patients who suffer from insomnia may experience improvements not only in their quality of sleep but also in their quality of life with nonpharmacologic therapies such as acupuncture and cognitive-behavioral therapy for insomnia (CBT-I), a new study concludes.

The study will be presented at the forthcoming American Society of Clinical Oncology (ASCO) 2018 annual meeting on June 3 (abstract 10001). The results were highlighted at a press briefing held ahead of the meeting.

The trial involved 160 patients with a variety of cancer types who experienced insomnia. The patients were randomly assigned to receive either CBT-I or accupuncture for 8 weeks.

The researchers report that all patients experienced a clinically meaningful benefit with either acupuncture or CBT-I, although the latter was significantly more effective, particularly for those with mild insomnia.

In addition, both treatments led to improvements in quality of life.

Lead researcher Jun J. Mao, MD, chief, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City, said in a release: "Up to 60% of cancer survivors have some form of insomnia, but it is often underdiagnosed and undertreated."

"Our trial showed that both CBT-I and acupuncture were effective in treating moderate to severe insomnia, although CBT-I was more effective for those with mild symptoms of insomnia," the researchers concluded.

"Our hope is that, by doing this type of research, we can help patients and clinicians pick the right kind of treatments for them to manage their sleep," Mao commented.

"Our next step is to examine in what type of patients each treatment may be beneficial and how to deliver these types of effective treatments to a broader community of cancer patients," he added.

Advantages Over Drugs

Nonpharmacologic approaches have advantages over drug treatment for insomnia, but this new study "does not have a placebo control, so the new knowledge gained is limited," commented David S. Black, MD, MPH, assistant professor of preventive medicine at the Keck School of Medicine, University of Southern California (USC), and faculty member at the USC Norris Comprehensive Cancer Center, Los Angeles, who was approached for an independent comment.

"Insomnia is often treated with pharmacotherapy," Black told Medscape Medical News.

He pointed out that "drug treatments provide only temporary remediation of sleep disturbance for some persons, the benefits often diminish after drug discontinuation, and there is risk for residual daytime effects and dependency syndrome."

Nonpharmacologic treatments such as CBT-I "have advantages over pharmacotherapy in that they are somewhat effective at improving sleep for both short-term and long-term periods and have no serious contraindications.

"There are repeated studies available showing the benefits of CBT-I for insomnia, making it one of the stronger clinical options. However, CBT-I is intensive and requires high commitment from both patients and highly trained therapists," he said.

"Acupuncture is a more passive treatment option for patients, making it potentially more attractive despite being less effective than CBT-I," he added.

Study Details

For the trial, Mao and colleagues recruited 160 patients who had completed cancer treatment for breast (31%), prostate (23%), hematologic (8%), head and neck (7%), and colorectal cancer (6%), among other types. The mean time since diagnosis was 6 years. The majority (70%) of patients were white; 28% were black.

After structured clinical interviews, the patients were assigned to receive 8 weeks of either acupuncture or CBT-I. The follow-up period was 12 weeks.

Acupuncture involved needles being placed at predetermined points on the body that have previously been shown to influence sleep, pain, and depression. Patients assigned to CBT-I worked with a therapist on sleep restriction, stimulus control, cognitive restructuring, relaxation training, and education.

Mao said that after 8 weeks, "both treatments produced a clinically meaningful benefit," with a reduction on the Insomnia Severity Index (ISI) of 8.3 points among patients given acupuncture and 10.9 points among those assigned to CBT-I. Improvements were maintained during follow-up.

Overall, CBT-I was significantly more effective than acupuncture (mean difference in ISI scores, 2.6; P = .0007).

For 33 patients who had mild insomnia at baseline (defined as an ISI score of 8 - 14), CBT-I was markedly more effective than acupuncture. The response rate was 85% for those who received CBT-I, vs 18% for those who underwent acupuncture (P < .0001).

Among the 127 patients with moderate to severe insomnia (ISI score ≥15), the treatments were equally effective. The response rate was 75% with CBT-I, vs 66% with acupuncture (P = .26).

Both the acupuncture and CBT-I groups experienced improvements in quality-of-life scores on the Patient-Reported Outcomes Measurement Information System. There were no significant differences on either the physical health (P = .40) or mental health scales (P = .36).

ASCO President Bruce Johnson, MD, said in a statment: "We know that sleep is critical to the health of patients with cancer, from active cancer care through survivorship. This research reinforces the understanding that there are a variety of effective, nonmedical tools, including psychological counseling and acupuncture, that can improve sleep and insomnia beyond traditional medicines, which can cause side effects that may diminish quality of life in other ways."

The study received funding from the Patient-Centered Outcomes Research Institute. One of the coauthors, Philip W. Kantoff, MD, has relationships with a number of pharmaceutical and technology companies .

American Society of Clinical Oncology (ASCO) 2018. Abstract 10001, to be presented June 3, 2018.

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