Judith R. Davidson

Sleep disturbance in cancer patients

Sleep difficulty is a prominent concern of cancer patients, yet there has been no large study of the prevalence and nature of sleep disturbance in cancer patients. This cross-sectional survey study examined: (a) the prevalence of reported sleep problems in patients attending six clinics at a regional cancer centre; (b) sleep problem prevalence in relation to cancer treatment; and (c) the nature of reported insomnia (type, duration, and associated factors). For three months, all patients attending clinics for breast, gastrointestinal, genitourinary, gynecologic, lung, and non-melanoma skin cancers were offered a brief sleep questionnaire. Response rate was 87%; the final sample size was 982. Mean age of respondents was 64.9 years (SD 12.5). The most prevalent problems were excessive fatigue (44% of patients), leg restlessness (41%). insomnia (31%), and excessive sleepiness (28%). Chi square tests showed significant variation among clinics in the prevalence of most sleep problems. The lung clinic had the highest or second-highest prevalence of problems. The breast clinic had a high prevalence of insomnia and fatigue. Recent cancer treatment was associated with excessive fatigue and hypersomnolence. Insomnia commonly involved multiple awakenings (76% of cases) and duration > or = 6 months (75% of cases). In 48% of cases, insomnia onset was reported to occur around the time of cancer diagnosis (falling within the period 6 months pre-diagnosis to 18 months post-diagnosis). The most frequently identified contributors to insomnia were thoughts, concerns, and pain/discomfort. In a multivariate logistic regression analysis, variables associated with increased odds of insomnia were fatigue, age (inverse relationship), leg restlessness, sedative/hypnotic use, low or variable mood, dreams, concerns, and recent cancer surgery. This study provides new information about sleep-related phenomena in cancer patients, information which will be useful in planning supportive care services for cancer patients.

Lung cancer treatment decisions: patients’ desires for participation and information

This study examined responses of 21 lung cancer outpatients to questions about their desired and actual levels of involvement in treatment decisions, and about information needed for treatment decision‐making. A ‘treatment trade‐off’ interview was used to assess patients’ preferences for hypothetical treatment options. Desired roles in decisions are examined in relation to treatment preference and information needs. Forty‐three percent of patients recalled desiring an active/collaborative role in their real treatment decision. For 29% of patients, there was a discrepancy between their recalled desired role and their recalled actual role; in each of these cases the patient had been less involved in the decision than they had desired. At the time of the interview (mean 26 months post‐treatment), 57% of patients desired an active or collaborative role in treatment decisions. The majority of patients rated the following types of information as ‘essential’ to treatment decisions: details of the treatment regimen, early and late side‐effects, survival, and effects of treatment on disease symptoms. The data suggest that: we should be attentive to the individuals desired role in treatment decisions at each step of care to avoid a mismatch between desired and actual involvement; desired role in decision‐making does not predict treatment preference; and patients generally want a wide variety of information on treatment options in order to participate in treatment decisions. Copyright

Patterns of reporting health-related quality of life outcomes in randomized clinical trials: implications for clinicians and quality of life researchers

PurposeTo assess the patterns of, and trends over time in, health-related quality of life (HRQL) reporting in randomized controlled trials (RCTs).MethodsThe English-language literature of RCTs published in 2002–2008 was identified using Medline, Embase, and Healthstar databases, in addition to the Cochrane Clinical Trials Registry. Eligible trials were phase III studies that included an HRQL outcome. Data were abstracted on eight outcomes derived from previously recommended quality standards for reporting HRQL, and on four outcomes describing how HRQL data are presented in RCT reports. Two readers examined each article; discrepancies were resolved through discussion and third review if required.ResultsA sample of 794 RCTs was identified. HRQL was a primary outcome in 25.4% (200/794). One hundred and ten RCTs (14%) used “supplementary” reports (separate from the first publication) to report HRQL findings. The proportion of RCTs that met the eight quality indicators ranged from 15% (HRQL used in the calculation of sample size) to 81% (reporting instrument validity). RCTs with HRQL as a primary outcome or with a supplementary report had higher concordance on the quality measures. Reporting improved on many indicators over time. Substantive variation in how HRQL data are presented in RCTs was evident.ConclusionsCurrent practice of reporting HRQL outcomes in RCTs remains highly variable, both with regard to quality of reporting and the patterns of data analysis and presentation. This variation presents challenges for clinicians to apply these data in clinical practice. Consistent reporting practices, which are interpretable by clinicians, are required, as are processes to achieve this consistency in future reports.

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.

Characteristics of Individuals With Insomnia Who Seek Treatment in a Clinical Setting Versus Those Who Volunteer for a Randomized Controlled Trial

The generalizability of outcome data derived from insomnia clinical trials is based largely on the extent to which research volunteers resemble clinical patients. This study compared sociodemographic, sleep, psychological, and medical characteristics of individuals who volunteered for an insomnia treatment study (n = 120) to patients who sought treatment in a clinical setting (n = 106). The samples did not differ on most sleep and medical variables, but clinical patients had a higher prevalence of mood disorders, greater anxiety and depression symptoms, and higher perceived insomnia severity. Differences on psychological variables were accentuated by the research selection process. It is suggested to minimize exclusion based on psychological comorbidity in order to enhance ecological validity of randomized controlled trials of insomnia treatments.

Young drivers' perceptions of culpability of sleep-deprived versus drinking drivers.

INTRODUCTION Sleep-deprived driving can be as dangerous as alcohol-impaired driving, however, little is known about attitudes toward sleep-deprived drivers. This study examined the extent to which young drivers regard sleep-deprived compared to drinking drivers as culpable for a crash, and how their perceptions of driving while in these conditions differ. METHOD University student participants (N=295; M=20.4years, SD=1.3; 81% women) were randomly assigned to read one of five fatal motor-vehicle crash scenarios, which differed by aspects of the drivers condition. Culpability ratings for the drinking driver were higher than those for the sleep-deprived driver. RESULTS Qualitative findings revealed that driving while sleep-deprived was viewed as understandable, and driving after drinking was viewed as definitely wrong. The dangers of sleep-deprived driving remain under-recognized.

Insomnia Treatment Options for Women

This article describes the circumstances under which women may develop insomnia and the various treatment options, including hypnotic medication and nonpharmacologic approaches. The efficacy and safety of these treatments are reviewed. The choice of treatment depends on the nature of the insomnia, the stage of a womans life, the presence of medical or mental health conditions, the availability of treatments, and personal preference. For immediate, short-term relief of acute insomnia, hypnotic medication, especially the nonbenzodiazepines (zolpidem, zopiclone, eszopiclone) are options. For chronic insomnia, insomnia-specific cognitive and behavioral therapies are generally the interventions of choice.

Sleep disturbance interventions for oncology patients: steps forward and issues arising.

Until the last 12 years, sleep disturbance in cancer patients was not givenmuch thought in theworld of oncology. Research and clinical work was focused on treatments to deal with the disease of cancer. When sleep problems were reported in the cancer clinic, they were often assumed to be due to pain at night, or stimulation from corticosteroids, and attempts were made to treat the pain or to alter the dose of medications; or benzodiazepines were prescribed. Insomniawas seenverymuchasa “secondary” symptom rather than a symptom or issue onto itself. But since 2000, there has been a surge of research on sleep itself in the context of cancer.With that has come researchonhowto treat sleep disturbance–primarily insomnia. This has been aided by a reconceptualization of insomnia as not secondary, but insomnia “comorbid”with cancer.1 The review article by Langford et al.2 highlights the interest in finding efficacious non-pharmacologic interventions for insomnia in this population. The authors discover that in the 1980s and 1990s, only two insomnia intervention studies were published. However, the field really took off in the 2000s, with 45 publications on this topic. As the authors say, “the field of sleep disturbance intervention research is still in its infancy.” Yes, we have just begun. Yet, these interventions for cancer patients are now far better researched than are hypnotic medications for this patient population. In fact, randomized controlled trials of hypnotic medication for cancer patients are noticeably absent. Compared to work on insomnia in the contextof othermedical illness, the cancer-insomnia intervention field is probably one of the best researched to date. Although there has been research on insomnia interventions for pain conditions,3,4 studies onothermedical disorders are sparse.With fewexceptions,5,6 we know little about using non-pharmacologic approaches for sleep disturbance in the context of many illnesses including common conditions such as heart disease, lung disease, kidney disease, gastrointestinal conditions, neurologic disorders and others.

Effectiveness of Group Cognitive Behavioral Therapy for Insomnia (CBT-I) in a Primary Care Setting

ABSTRACT Objective/Background: Primary care is where many patients with insomnia first ask for professional help. Cognitive-behavioral therapy for insomnia (CBT-I) is the recommended treatment for chronic insomnia. Although CBT-I’s efficacy is well established, its effectiveness in real-life primary care has seldom been investigated. We examined the effectiveness of CBT-I as routinely delivered in a Canadian primary care setting. Participants: The patients were 70 women and 11 men (mean age = 57.0 years, SD = 12.3); 83% had medical comorbidity. Methods: For the first 81 patients who took the six-session group program we compared initial and postprogram sleep diaries, sleep medication use, Insomnia Severity Index (ISI), the Hospital Anxiety and Depression Scale (HADS), and visits to the family physician. Results: Sleep onset latency, wake after sleep onset, total sleep time, sleep efficiency, and ISI scores improved significantly (p < .001). Mood ratings also improved (p < .001). Use of sleep medication decreased (p < .001). Effect sizes were medium to large. Eighty-eight percent of patients no longer had clinically significant insomnia (ISI score ≤ 14) by the last session; 61% showed at least “moderate” improvement (ISI score reduction > 7). Wait-list data from 42 patients showed minimal sleep and mood improvements with the passage of time. Number of visits to the family physician six months postprogram decreased, although not significantly (p = .108). Conclusions: The CBT-I program was associated with improvement on all sleep and mood measures. Effect sizes were similar to, or larger than, those found in randomized controlled trials, demonstrating the real-world effectiveness of CBT-I in an interdisciplinary primary care setting.