Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients

Figures & data

Table 1 Uncontrolled trials of cognitive behavioral therapy for insomnia (CBT-I) in cancer patients

Study	Year	Sample/sex	Diagnosis/stage	Tx status	Design	Assessment times	Tx description	Intervention details	Outcome measures	Main results
Davidson et al^Citation61	2001	12/males and females	Mixed/no active disease	Posttreatment	Single group	T1 – Week 0 T2 – Week 4 T3 – Week 8	SC, RT, SH, CR	Group Six session Weekly ×5, then monthly ×160–90 minutes	SD: SL, NWAK, WASO, TST, SE SII HADS, QLQ-C30	↓ NWAK (0.002), WASO (0.001) ↑ TST (0.03), SE (<0.001) ↓ sleep-related impairment (<0.001) No significant ↓ in depression, anxiety or ↑ quality of life at T3
Quesnel et al^Citation62	2003	10/females	Breast/I–III	Posttreatment	Multiple-baseline Single subject	T1 – Week 0 T2 – Week 8 T3 – Week 32	SC, SR, CR, SH fatigue management, RP	Group Eight session Weekly 90 minutes	WASO, TST (PSG) ISI BDI, STAI, MFI, QLQ-C30	PSG: ↓ WASO (0.02); ↑ SE (0.04) 86% clinically significant ↓ in ISI at T3 No significant ↓ in depression, anxiety, fatigue or ↑ quality of life at T3
Simeit et al^Citation65	2004	229/males and females	Mixed/no active disease	Posttreatment	Three group (PMR, AT, or UC)	T1 – Week 0 T2 – Week 4 T3 – Week 10 T4 – Week 34	Patients chose PMR or AT. Tx groups were provided with information on SC, SR, CR, SH (not formal CBT-I)	Group Three session Weekly 60 minutes	PSQI QLQ-C30	Both Tx groups: ↓ SL (<0.001), sleep disturbance (<0.001) ↑ sleep duration (<0.001), SE (<0.001), sleep quality (<0.001), daytime function (<0.001) All groups ↑ quality of life at T4
Savard et al^Citation64	2011	11/females	Breast/I–III	Post-radiation	Single group	T1 – Week 0 T2 – Week 6 T3 – Week 18	SC, SR, CR, SH, RP	Self-administered DVD/booklet Six modules Weekly 60 minutes	SD: SL, WASO, TST, SE ISI HADS, MFI, QLQ-C30, DBAS	↓ SL (0.01), WASO (<0.001) ↑ SE (<0.001), TST (ns) ↓ insomnia severity (<0.001) Significant ↓ depression (0.03), dysfunctional beliefs (0.001) and ↑ quality of life (0.03). No significant ↓ anxiety or fatigue at T3

Abbreviations: AT, autogenic training; BDI, Beck Depression Inventory; CR, cognitive restructuring; DBAS, Dysfunctional Beliefs and Attitudes about Sleep; HADS, Hospital Anxiety and Depression Scale; ISI, Insomnia Severity Index; MFI, Multidimensional Fatigue Inventory; NWAK, number of awakenings; PMR, progressive muscle relaxation; PSG, polysomnography; PSQI, Pittsburgh Sleep Quality Index; QLQ-C30, Quality of Life Questionnaire – Cancer; RP, relapse prevention; RT, relaxation training; SC, stimulus control; SE, sleep efficiency; SD, sleep diary; SH, sleep hygiene; SII, Sleep Impairment Index; SL, sleep latency; SR, sleep restriction; STAI, State-Trait Anxiety Inventory; TST, total sleep time; Tx, treatment; UC, usual care; WASO, wake after sleep onset; ns, non-significant; ↑, increase; ↓, decrease.

Table 2 Controlled studies of cognitive behavioral therapy for insomnia (CBT-I) in cancer patients

Study	Year	Sample/sex	Diagnosis/stage	Tx status	Tx – treatment(s) C – control	Intervention details	Assessment times	Outcome measures	Main results*
Savard et al^Citation67	2005	57/females	Breast/I–III	Posttreatment	Tx – SC, SR, CR, SH, fatigue and stress management C – waitlist	Group Eight sessions Weekly 90 minutes	T1 – Week 0 T2 – Week 8 T3 – Week 20 T4 – Week 32 T5 – Week 52	SL, WASO, TST, SE (SD and PSG) ISI HADS, MFI, QLQ-C30	SD: ↓ SL, WASO, ↑ SE, TST (all <0.01) PSG: ↓ SL (0.001), WASO (0.05), ↑ SE (0.05) ↓ insomnia severity (<0.001) Significant ↓ depression (0.001), anxiety (0.001), fatigue (0.001) and ↑ quality of life (0.0001)
Savard et al^Citation68	2005							Blood-cell counts and cytokines	↑ IFN-γ, IL1β, WBC, lymphocytes
Epstein and Dirksen^Citation69	2007	72/females	Breast/I–III	Posttreatment	Tx – SC, SR, SH C – sleep education and hygiene	Group Six sessions Weekly ×4, phone ×2 30–120 minutes	T1 – Week 0 T2 – Week 6	SL, WASO, TST, SE (SD and actigraphy)	Both groups: SD: ↓ SL, WASO, ↑ SE, TST (all <0.001) Actigraphy: ↓ SL (0.03), WASO (0.03), ↑ TST (0.02)
Espie et al^Citation66	2008	150/males and females	Mixed/no active disease	Posttreatment	Tx – SC, SR, CR C – treatment as usual	Group Five sessions Weekly 50 minutes	T1 – Week 0 T2 – Week 6 T3 – Week 30	SL, WASO, TST, SE (SD and actigraphy) HADS, FACT-G, FSI	SD: ↓ SL (~16 min), WASO (~38 min), ↑ SE (~10%), all <0.001 Actigraphy: significant ↓ at T2 but not T3 Significant ↓ depression (0.004), anxiety (0.011), fatigue (0.001) and ↑ quality of life (0.001) at T3
Berger et al^Citation70	2009	219/females	Breast/I–IIIA	Pre-, during, and post-chemo	Tx – modified SC, modified SR, RT, SH C – diet education	Individual Before, biweekly during, 30 days after chemo 15–30 minutes	T1 – pre-chemo T2-T8 – during chemo T9 – 30 days post-Tx	SL, WASO, TST, SE (SD and actigraphy) PSQI PFS	SD: ↓ WASO (0.03), ↑ SE (0.001) Actigraphy: significant ↓ WASO (0.03) ↓ sleep disturbance (0.05) Fatigue ↓ in both groups at T6
Berger et al^Citation71	2009						T1 – 30 days post-chemo T2 – 60 days post-chemo T3 – 90 days post-chemo T4 – 1 year post-chemo	SL, WASO, TST, SE (SD and actigraphy) PSQI PFS, SES, HADS, MOS-SF-36	No significant sleep diff between groups at T4 Significant ↓ sleep disturbance (0.02) in Tx group at T4 Both groups significantly improved at T4
Fiorentino et al^Citation72	2010	14/females	Breast/I–III	Posttreatment	Tx – SR, SC, SH, RT, CR C – waitlist	Individual Six sessions Weekly60 minutes	T1 – Week 0 T2 – Week 6 T3 – Week 13	SL, WASO, TST, SE (SD and actigraphy) PSQI, ISI	SD: ↓ WASO (0.002), ↑ SE (0.01), NWAK (0.02) Actigraphy: ↓ NWAK (0.05), WASO (0.009), ↑ TST (0.03), Significant ↓ insomnia severity (0.001), ES =10.4; ↓ sleep disturbance (0.002), ES =0.8 at T3
Ritterband et al^Citation74	2012	28/males and females	Mixed/no active disease	Posttreatment	Tx – SR, SC, SH, CR, RP (Internet based) C – waitlist	Individual Six sessions over 9 weeks45–60 minutes	T1 – Week 0 T2 – Week 10	SD: SL, NWAK, WASO, TST, SE ISI HADS, MFSI, MOS-SF-12	↓ SL (0.03), ↑ SE (0.01), NWAK, WASO, TST (all ns) Significant ↓ insomnia severity (0.01), ES =1.85 ↓ fatigue (0.01), no significant change in depression, anxiety or quality of life
Garland et al^Citation77	2014	111/males and females	Mixed/no active disease	Posttreatment	Tx1 – SR, SC, SH, CR, RT, RP Tx2 – MBSR	Group Eight session Weekly 90 minutes	T1 – Week 0 T2 – Week 8 T3 – Week 32	SL, WASO, TST, SE (SD and actigraphy) ISI, PSQI, DBAS POMS-SF, CSOSI	SD: Tx1 ↓ SL (0.004), ↑ SE (0.008) Both groups: ↓ WASO (0.001) ↑ SE (0.001) Actigraphy: SL (ns), ↓ WASO (0.001), ↑ TST, SE (0.001) in both groups Tx1: significant ↓ insomnia severity, sleep disturbance, dysfunctional beliefs at T3 Both groups significant ↓ stress and mood symptoms
Savard et al^Citation76	2014	260/females	Breast/I–III	Posttreatment	Tx1 – SR, SC, CR, SH (clinician delivered) Tx2 – SR, SC, CR, SH (video based) C – treatment as usual	Individual Six session Weekly 50–60 minutes	T1 – Week 0 T2 – Week 6	SL, WASO, TST, SE (SD and actigraphy) ISI, DBAS MFI, HADS, EORTC QLQ-C30	SD: no diff between Tx1 and Tx2 on ↓ SL (0.13), WASO (0.24), ↑ SE (0.13) Actigraphy: TST increased in Tx1 only (0.04) Significant ↓ insomnia severity (0.03), dysfunctional beliefs (for Tx1 only) Greater ↓ in fatigue, anxiety and depression in Tx1. Quality of life ↑ in all three groups

Note:

* Group by time interactions are presented unless otherwise specified.

Abbreviations: C, control; CR, cognitive restructuring; CSOSI, Calgary Symptoms of Stress Inventory; DBAS, Dysfunctional Beliefs and Attitudes About Sleep; EORTC QLQ-C30, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire; ES, effect size; FACT-G, Functional Assessment of Cancer Therapy – General; FSI, Fatigue Symptom Inventory; HADS, Hospital Anxiety and Depression Scale; IFN-γ, interferon gamma; IL1β, interleukin-1-beta; ISI, Insomnia Severity Index; MBSR, mindfulness-based stress reduction; MFI, Multidimensional Fatigue Inventory; MFSI, Multidimensional Fatigue Symptom Inventory; MOS-SF-36, Medical Outcomes Study Short-Form General Health Survey; MOS-SF-12, Medical Outcomes Study Short-Form General Health Survey (Short version); NWAK, number of awakenings; PFS, Piper Fatigue Scale; POMS-SF, Profile of Mood States, Short Form; PSG, polysomnography; PSQI, Pittsburgh Sleep Quality Index; QLQ-C30, Quality of Life Questionnaire – Cancer; RP, relapse prevention; RT, relaxation training; SC, stimulus control; SE, sleep efficiency; SD, sleep diary; SES, Symptom Experience Scale; SH, sleep hygiene; SL, sleep onset latency; SR, sleep restriction; T, time effect; TST, total sleep time; Tx, treatment; WASO, wake after sleep onset; WBC, white blood cells; chemo, chemotherapy; diff, difference; min, minutes; ns, non-significant; ↑, increase; ↓, decrease.

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