Sleep and cancer: Uncomfortable bedfellows

Newly-diagnosed cancer patients face a number of life-long challenges, but a new study from the Duke Clinical Research Institute suggests that a lack of sleep may be one of the most persistent and disruptive.

"Sleep problems among cancer patients may be often overlooked because so many other issues, such as surgery, radiation or chemotherapy, arise so urgently," says Kevin Weinfurt, PhD, associate professor in the departments of psychiatry and behavioural sciences and psychology and neuroscience at Duke. "Our study found that when it comes to overall impact upon quality of life, sleep disruption is highly significant." 

The study, reported in the journal Psycho-Oncology, is part of a National Institutes of Health Roadmap initiative designed to improve the measurement of how patients feel and function, called the Patient-Reported Outcomes Measurement Information System (PROMIS) Network. 

Earlier studies have shown that about half of all cancer patients report some sort of sleep disruption and that some of these problems remain long after treatment ends.

Weinfurt says the current study is among the first to use qualitative methods to better understand how sleep disturbance affects the quality of patients’ lives. He adds that the findings may offer clinicians new directions for earlier assessment and intervention. 

Weinfurt, along with Kathryn Flynn, PhD, assistant professor of psychiatry and behavioural sciences at Duke, mailed invitations to patients in the Duke University tumor registry and contacted them in person at the Duke Comprehensive Cancer Center to recruit 67 participants for ten focus groups. Each group had from 6 to 12 members. Seven of the groups were comprised of patients actively undergoing treatment; three included only patients who were post-treatment.  

Researchers asked the groups to discuss their experience with sleep since their diagnosis and took notes as the conversations ensued. Discussions focused on four topics: the scope and importance of sleep, the impact of cancer on sleep, the consequences of sleep difficulties on daytime functioning and quality of life, and the management of sleep difficulties.

The patients reported that:

• Sleep disruption was a major problem for many of them;
• Hot flashes and night sweats were a major cause of sleep disturbance;
• Sleepiness/tiredness/fatigue was led to less daytime wakefulness and less overall ability to function normally;
• Many experienced anxiety about prognosis or recurrence;
• Many also held strong beliefs that healthy sleep was necessary for healing;
• Patients also noted that finding a comfortable sleeping position was difficult, with many of them citing surgical site tenderness, radiation burns or medical devices like ports, tubing or ostomy as obstacles to sleep.

While sleep disruption is sometimes associated with illness, cancer patients in particular may be more vulnerable because specific treatments, like hormone therapy and chemotherapy, can lead to physiological side effects associated with insomnia and fatigue. Some studies have also found a relationship between insomnia and an impaired immune system, the authors note.  

"Our data suggest that health care providers who care for patients with cancer should be mindful of the many types of sleep disorders associated with cancer. They also need to recognise that patients feel that high quality sleep is an important factor in their fight against cancer," says Flynn. 

Flynn says the study findings underscore the need for screening cancer patients for disturbed sleep and daytime sleepiness. If sleep disturbance is identified, behavioural, psychological, or pharmacological treatments should be discussed, she says.  

"There is a growing body of literature addressing the effectiveness of treatments for fatigue," Flynn says. "However, less evidence is available to guide the management of insomnia in patients with cancer. As health care providers, we can do better. This is definitely an area that needs more attention." 

(Source: Duke University Medical Centre: Psycho-Oncology: December 2009)