Stepped-Care Approach Can Effectively Treat Insomnia in Cancer Survivors

By Marilynn Larkin

September 26, 2019

NEW YORK (Reuters Health) – A "sizable proportion" of cancer survivors with insomnia can benefit from a stepped-care approach, starting with a single sleep-education session that can be delivered by a non-sleep specialist, researchers say.

"Despite successfully putting cancer in their rear-view mirror, a significant number of survivors continue to deal with the consequences of their diagnosis and treatment," Dr. Eric Zhou of the Dana-Farber Cancer Institute in Boston said in an email to Reuters Health. "Affecting up to one in four cancer survivors, insomnia is one of the most common problems and perhaps one of the most impactful on their health and everyday well-being."

"The use of brief interventions (minimizing patient burden) requiring minimal clinician training (maximizing provider availability), such as our program, can be a game changer for cancer centers across the (U.S.) that are unable to have a sleep specialist on staff, but wish to help their patients properly manage a significant medical issue after their cancer treatment has ended," he said.

Dr. Zhou and colleagues enrolled 51 cancer survivors into the Sleep Training Education Program (STEP), which consists of two intervention levels. STEP-1 is sleep education, delivered in a single, hour-long session by a clinical psychologist.

STEP-2 is the next intervention level, a three-session, group-based cognitive behavior therapy program (CBT-1) previously developed and tested for adult survivors. Sessions were led by the study investigators and supplemented by a workbook.

As reported online September 24 in Cancer, participants had a mean age of 55; 89% were women, and 91%, Caucasian. The mean number of years since cancer diagnosis was 10.2; close to two-thirds (63.6%) had breast cancer; and all had elevated Insomnia Severity Index (ISI) scores (12 or greater).

All participants first received STEP-1. Those reporting elevated ISI scores one month later were offered STEP-2. Participants were considered "treatment responders" if their ISI score improved by six or more points and "remitted" if their post-treatment ISI score was <12. Mood was assessed with the Profile of Mood States-Short Form Total Mood Disturbance (POMS-SF TMD).

Follow-up sleep treatment change questions were administered at four and eight weeks.

Four weeks after STEP-1, mean ISI scores improved from 17.1 to 11.2, with 45% responding to treatment and 41% remitted. Insomnia remission after STEP-1 was associated with lower insomnia severity and shorter duration of sleep problems at baseline.

Overall, mean ISI scores changed from 17.3 to 11.9 and the POMS-SF TMD score changed from 15.6 to 9.4.

Of the 30 survivors (59%) with unremitted insomnia after STEP-1, 14 (47%) participated in STEP-2. STEP-2 participation was associated with interest in sleep treatment at baseline, but not demographic/health-related variables.

Following STEP-2, ISI scores improved from 16.9 to 8.8, with 79% responding and 71% remitted. POMS-SF TMD also improved, but the difference from baseline was significant only at eight weeks, not four.

"We are working to automate the delivery of the low-intensity intervention through a video-based program," Dr. Zhou noted. "By removing the human element, we might reduce the impact the program has on a patient but, in turn, could increase the number of patients who can access the program tremendously."

"Further," he added, "finding ways that we can help to train cancer clinicians in the field will be an important piece of our work moving forward."

Dr. Guy Maytal, Chief of Integrated Care and Psycho-oncology at NewYork-Presbyterian and Weill Cornell Medicine in New York City, commented by email, "I definitely agree with this approach. A screening-based, stepwise approach towards the management of insomnia allows all patients to be adequately assessed and for the dose of the intervention to be titrated to the patient's needs."

"I routinely educate patients in sleep hygiene techniques and follow-up to see how they implement them," he told Reuters Health. "I refer patients for CBT-I when insomnia is the primary symptom and when patients are motivated to participate. We are working on implementing universal screening for cancer patients."

"As the authors of this paper indicate, patients with long-standing sleep disturbances are less likely to respond to first-line interventions and often need a thorough evaluation by a sleep expert," he said. "In such situations, the insomnia may be along-standing condition that is unrelated to the patient's history of cancer."

"Insomnia is often a leading symptom of other syndromes," he added. "These can include major depression, anxiety, and medication side effects. Clinicians should be vigilant for such syndromes when patients present with insomnia."


Cancer 2019.