Marie-Hélène Savard

Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial.

STUDY OBJECTIVE To assess the short-term efficacy of a video-based cognitive behavioral therapy for insomnia (CBT-I) as compared to a professionally administered CBT-I and to a no-treatment group. DESIGN Randomized controlled trial. SETTING Radio-oncology department of a public hospital affiliated with Université Laval (CHU de Québec). PARTICIPANTS Two hundred forty-two women with breast cancer who had received radiation therapy in the past 18 mo and who had insomnia symptoms or were using hypnotic medications were randomized to: (1) professionally administered CBT-I (PCBT-I; n = 81); (2) video-based CBT-I (VCBT-I; n = 80); and (3) no treatment (CTL; n = 81). INTERVENTIONS PCBT-I composed of six weekly, individual sessions of approximately 50 min; VCBT-I composed of a 60-min animated video + six booklets. MEASUREMENT AND RESULTS Insomnia Severity Index (ISI) total score and sleep parameters derived from a daily sleep diary and actigraphy, collected at pretreatment and posttreatment. PCBT-I and VCBT-I were associated with significantly greater sleep improvements, assessed subjectively, as compared to CTL. However, relative to VCBT-I, PCBT-I was associated with significantly greater improvements of insomnia severity, early morning awakenings, depression, fatigue, and dysfunctional beliefs about sleep. The remission rates of insomnia (ISI < 8) were significantly greater in PCBT-I as compared to VCBT-I (71.3% versus 44.3%, P < 0.005). CONCLUSIONS A self-administered cognitive behavioral therapy for insomnia (CBT-I) using a video format appears to be a valuable treatment option, but face-to-face sessions remain the optimal format for administering CBT-I efficaciously in patients with breast cancer. Self-help interventions for insomnia may constitute an appropriate entry level as part of a stepped care model. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00674830. CITATION Savard J, Ivers H, Savard MH, Morin CM. Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer? Results of a randomized controlled trial.

The Influence of Breast Cancer Treatment on the Occurrence of Hot Flashes

Approximately 65% of women report hot flashes (HFs) during or following breast cancer treatment. However, few studies have compared the occurrence of vasomotor symptoms according to the type of adjuvant treatment received, and little is known about other risk factors for HFs among this population. This longitudinal study aimed to: 1) compare the frequency and severity of HFs in breast cancer patients according to treatment regimen; 2) evaluate the potential contribution of hormone therapy on the frequency and severity of HFs; and 3) identify other potential risk factors for HFs in breast cancer patients. Forty-one women receiving radiation therapy and chemotherapy and 40 women receiving radiation therapy without chemotherapy completed a daily diary of HFs for seven days, and the vasomotor scale of the Menopause-Specific Quality of Life Questionnaire prior to and following each type of treatment, and at a three-month follow-up evaluation. Z-scores and percentiles computed from an age-matched control group (n=45) without a history of cancer revealed a higher frequency and severity of HFs among breast cancer patients compared with control participants. Chemotherapy and hormone therapy were both associated with increased HFs. Past use of hormone replacement therapy (HRT) and a lower body mass index (BMI) were significantly associated with more severe vasomotor symptoms. This study highlights the clinical significance of HFs among breast cancer patients, particularly in women receiving chemotherapy and hormone therapy, and the necessity to offer effective therapeutic strategies to relieve HFs in this population.

Relationship between objectively recorded hot flashes and sleep disturbances among breast cancer patients: investigating hot flash characteristics other than frequency.

Objective The aim of this study was to evaluate the relationship between various characteristics of objectively recorded hot flashes and sleep disturbances in breast cancer patients. Methods Fifty-six women who had completed a similar treatment protocol for a first diagnosis of breast cancer within the previous 3 months wore ambulatory sternal skin conductance and polysomnography devices for a home-based nighttime recording of hot flashes and sleep. Results Hot flash frequency was not associated with polysomnographic variables (r = −0.18 to 0.21) or beta-I and beta-II electroencephalographic activities (r = −0.01 and 0.03) but was significantly correlated with increased slow (r = 0.28) and delta (r = 0.32) electroencephalographic activities. A slower hot flash onset and a longer hot flash duration were associated with greater polysomnographic impairments (r = −0.50 to 0.48). Greater sleep disturbances were found during hot flash onset or hot flash plateau as compared with the pre–hot flash period (greater percentage of wake time, lower percentage of stage II sleep, and lower percentage of rapid eye movement sleep, all P values < 0.05). The probability that a stage change to a lighter sleep occurred was significantly greater during hot flash onset (11%) than during hot flash plateau (6%; P = 0.02). Conclusions This study suggests that the speed and duration of hot flashes would contribute more importantly to sleep alterations than hot flash frequency. Sleep disturbances tend to occur simultaneously with hot flashes, suggesting that these two nocturnal symptoms are manifestations of a higher-order mechanism involving the central nervous system.

Psychological Distress Among Adolescents Living with a Parent with Advanced Cancer

The objective of this exploratory study was to evaluate the impact of advanced parental cancer on adolescents’ psychological status. A sample of 28 adolescents, having a parent with advanced cancer, was recruited and compared with a sample from the general population (N = 2,346). Late adolescents (age 15 to 18) experienced significantly more psychological distress than early adolescents (age 12 to 14). Moreover, late adolescents experienced significantly higher psychological distress than the general population for the same age group, which was not the case for early adolescents. Implications for adolescents living in families touched by advanced cancer are discussed.

Is Insomnia Associated With Cognitive Impairments in Breast Cancer Patients

Insomnia and cognitive impairment are both highly prevalent in breast cancer patients. This study, conducted among women treated for non-metastatic breast cancer, aimed at assessing the relationship between insomnia and cognitive functioning, measured objectively and subjectively, and evaluating the moderating role of age, educational level and intellectual potential. Sixty-three women completed a neuropsychological battery, self-report scales of cognitive functioning, 2 weeks of a daily sleep diary, and a demographic and medical questionnaire. Significant differences between women with insomnia and good sleepers were found on verbal episodic memory and executive functioning, assessed objectively, and some aspects of subjective cognitive functioning. Moreover, older age and a higher education were associated with more severe cognitive impairments related to insomnia.

Depression and androgen deprivation therapy for prostate cancer: a prospective controlled study.

OBJECTIVE The main goal of this controlled study was to compare the presence of depressive symptoms and disorders in men receiving a combination of androgen deprivation therapy and radiation therapy (ADT-RTH) to men receiving RTH only. METHOD A total of 60 men with nonmetastatic prostate cancer formed two groups: (a) ADT-RTH (n = 28) and (b) RTH only (n = 32). The ADT-RTH group was further subdivided between men who received long-term ADT (n = 17) and short-term ADT (n = 11). All participants were assessed prior to ADT initiation, and at seven additional times over a period of 16 months using semistructured interviews and self-report scales. RESULTS The prevalence of depressive disorders ranged from 5.5% to 23.0% over the study period. The introduction of ADT was associated with increases in depressive symptoms for some measures but these differences were not significant. Likewise, withdrawal of ADT was associated with consistent decreases in depressive symptoms, but none of these differences was significant. The small sample size may have limited the statistical power to detect those differences. However, calculations of effect sizes revealed that most of them were of a small magnitude. CONCLUSIONS To our knowledge, this is the first controlled study that investigated the possible role of ADT in the development of depression using prostate cancer patients who were not receiving ADT as controls. Overall, it appears that ADT does not represent a major risk factor for depression. This is good news for patients receiving this treatment who already have to adapt to many of its other side effects.

Long-Term Effects of Two Formats of Cognitive Behavioral Therapy for Insomnia Comorbid with Breast Cancer

STUDY OBJECTIVES The goal of this randomized controlled trial, conducted in breast cancer patients, was to assess the long-term efficacy of a video-based cognitive behavioral therapy for insomnia (VCBT-I), as compared to a professionally administered intervention (PCBT-I) and to a no-treatment group (CTL). An earlier report revealed that, at posttreatment, VCBT-I patients showed significantly greater sleep improvements than CTL, but that PCBT-I produced superior effects than VCBT-I on some sleep and secondary outcomes. In this report, long-term effects are compared. METHODS Two hundred forty-two women with breast cancer and with insomnia symptoms or using hypnotic medications participated to this three-arm randomized controlled trial: (1) PCBT-I (n = 81); (2) VCBT-I (n = 80); or (3) no treatment (CTL; n = 81) group. PCBT-I was composed of six weekly, individual sessions of approximately 50 min, whereas VCBT-I comprised a 60-min animated video and six booklets. RESULTS Study measures (sleep and secondary variables) were administered at pretreatment and posttreatment, and at a 3-, 6-, and 12-mo follow-up. Treatment gains were well sustained at follow-up in both PCBT-I and VCBT-I. As at posttreatment, the remission rate of insomnia at follow-up was greater in PCBT-I than in VCBT-I, which was greater than in CTL. CONCLUSIONS Although face-to-face therapy remains the optimal format to efficaciously administer CBT for insomnia in cancer patients, a minimal intervention, such as the video-based intervention tested in this study, produces significant and sustainable treatment effects. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier NCT00674830.

Sleep–wake difficulties in community-dwelling cancer patients receiving palliative care: subjective and objective assessment

OBJECTIVE Prevalence rates of sleep difficulties in advanced cancer patients have varied widely across studies (12 to 96%), and none of these employed a diagnostic interview to distinguish different types of sleep-wake disorders. Moreover, very limited information is available on subjective and objective sleep parameters in this population. Our study was conducted in palliative cancer patients and aimed to assess rates of sleep-wake disorders and subsyndromal symptoms and to document subjective and objective sleep-wake parameters across various types of sleep-wake difficulties. METHOD The sample was composed of 51 community-dwelling cancer patients receiving palliative care and having an Eastern Cooperative Oncology Group score of 2 or 3. Relevant sections of the Duke Interview for Sleep Disorders were administered over the phone. An actigraphic recording and a daily sleep diary were completed for 7 consecutive days. RESULTS Overall, 68.6% of the sample had at least one type of sleep-wake difficulty (disorder or symptoms): 31.4% had insomnia and 29.4% had hypersomnolence as their main sleep-wake problem. Participants with insomnia as their main sleep difficulty had greater disruptions of subjective sleep parameters, while objectively-assessed sleep was more disrupted in patients with hypersomnolence comorbid with another sleep-wake difficulty.Significance of the Results:The high rates of sleep-wake difficulties found in this study indicate a need to screen more systematically for sleep-wake disorders, including insomnia and hypersomnolence, in both palliative care research and clinical practice, and to develop effective nonpharmacological interventions specifically adapted to this population.

Cognitive-Behavioral Therapy for Insomnia in Cancer Patients: An Update of Efficacy Evidence and Areas for Future Research

Purpose of ReviewThis study aims to review the empirical evidence on the prevalence, evolution, and etiology of insomnia in cancer as well as on the efficacy of cognitive-behavioral therapy for insomnia (CBT-I) in this population.Recent FindingsInsomnia is highly prevalent and persistent during the cancer trajectory, especially in patients with breast and gynecological cancer. Surgery and hospitalization, adjuvant treatments, nocturnal hot flashes, fatigue, and pain may trigger the onset of sleep disturbances. Several clinical trials have supported the efficacy of CBT-I to improve sleep of cancer patients.SummaryCBT-I is now recognized as the treatment of choice for insomnia comorbid with cancer. However, its accessibility is limited in oncology settings and could be improved through the use of minimal interventions (e.g., self-administered). Future research should assess the patients’ acceptability and efficacy of CBT-I during the active phase of cancer treatment and in patients with advanced disease. Stepped care approaches and interventions targeting multiple cancer-related symptoms associated with the occurrence of insomnia could increase treatment efficacy and cost-effectiveness, but their utility needs to be empirically assessed.

Is anxiety associated with hot flashes in women with breast cancer

ObjectiveWomen with breast cancer are at higher risk for experiencing hot flashes (HFs), which is attributable, in large part, to systemic cancer treatments and their effects on estrogen levels. However, other factors, such as anxiety, could also play a role. This study aimed to assess the cross-sectional and temporal relationships between anxiety and HFs among women treated for breast cancer and to clarify the direction of these relationships. MethodsFifty-six women recently treated for breast cancer were assessed prospectively using a 14-day Hot Flashes and Anxiety Diary (HFAD). Anxiety and HFs were also assessed using the Hospital Anxiety and Depression Scale–anxiety subscale and the Menopause-Specific Quality of Life Questionnaire–vasomotor subscale. In addition, HFs were objectively recorded for a continuous 24-hour period using home-based sternal skin conductance. ResultsNo cross-sectional relationship was found between anxiety and subjectively assessed HFs, or between anxiety and the frequency and intensity of objectively assessed HFs. However, a greater anxiety level on the HFAD was significantly associated with a shorter time to reach the HF peak, as assessed with sternal skin conductance (partial Spearman correlation coefficient rsp = −0.44). Moreover, greater anxiety predicted more severe self-reported HFs on the following night, both assessed with the HFAD (rsp = 0.13). Conversely, self-reported diurnal and nocturnal HFs on the HFAD did not predict next-day anxiety level. ConclusionsThis study reveals a significant relationship between anxiety and faster-developing objectively measured HFs. Furthermore, anxiety has been found to significantly predict subsequent increases in self-reported HFs, suggesting that strategies that target anxiety could potentially have a beneficial effect on HFs in women with breast cancer.