Persistent insomnia which affects a third of cancer survivors can be greatly improved through cognitive behavioural therapy (CBT) – known as the ‘talking cure’ – given by cancer nurses, according to trial results published in the Journal of Clinical Oncology, today (Wednesday).
A Cancer Research UK-funded trial, run by the University of Glasgow Sleep Centre, analysed the effect of CBT on sleep quality in 150 participants who had completed cancer treatment. They had all reported chronic insomnia lasting an average of two years.
Participants were divided into two groups. One group received CBT from cancer nurses, who were trained to deliver the CBT but had no prior experience in sleep medicine. Cancer nurses were used in this trial to demonstrate that the therapy could be delivered by non sleep specialists. The other group followed their usual clinical practice.
The group receiving CBT reported that it eliminated an average of 55 minutes of wakefulness per night, straight after receiving the therapy. This group also reported less day fatigue, and reduced anxiety and depression. A six-month follow up showed there were still benefits, while those in the control group reported no change.
Professor Colin Espie, director of University of Glasgow Sleep Centre and lead author, said: “When people with cancer receive the all clear from their cancer they want to get on with their lives. Developing chronic insomnia can be a massive shock and a barrier to recovery. It causes fatigue, depression and anxiety and people often feel they have gone from one problem to another.
“Insomnia is seldom satisfactorily addressed in cancer patients. Once they have left the care system the thought of taking more medication is soul destroying but they don’t know what to do. Better psychological care, practical advice and information at all stages of their treatment are needed.”
The CBT was administered in five small group sessions of up to six participants across five consecutive weeks. Patients recorded results in sleep diaries for three ten day assessment periods. The diary measured behaviour such as sleep initiation, restlessness, waking from sleep in the night and sleep efficiency – percentage of time in bed spent asleep. Other outcomes measured included day-time fatigue and health-related quality of life.
Kate Arnold, Cancer Research UK’s patient information director, said: “Persistent insomnia is a troubling and debilitating problem which can erode quality of life. It is important to research realistic ways of overcoming insomnia in people recovering from cancer treatment and not accept it as something that goes with the territory.
“Patients need a full care programme with advice and information to identify and tackle problems such as insomnia both during their cancer treatment and after having the disease in order to enjoy life after cancer.”
For media enquiries please contact the Cancer Research UK press office on 020 7061 8300 or, out-of-hours, the duty press officer on 07050 264 059.
Colin A. Espie et al. Randomized controlled clinical effectiveness trial of cognitive behaviour therapy compared with treatment as usual for persistent insomnia in patients with cancer. Published in Journal of Clinical Oncology, Volume 26, Number 28, 1 October, 2008.
Participants had completed active therapy for breast, prostate, colorectal or gynaecological cancer. To take part in the test they had to satisfy diagnostic requirements for chronic insomnia: a mean delay of longer than 30 minutes to fall asleep and/or time spent awake after falling asleep, occurring three nights per week for three months and affecting daytime function. Participants also had to screen more than five on the Pittsburgh Sleep Quality Index which measures clinically significant sleep disturbance.
Their treatment (radiation or chemotherapy) had to be completed by more than a month before the trial started with no further anticancer treatment planned except adjuvant hormone therapy. Participants with acute illness, estimated prognosis of less than six months, confusion problems or drug misuse or patients with other evidence of sleep disorders such as sleep apnoea or of untreated psychiatric disorder were excluded.
Potential participants were recruited at hospitals within NHS Greater Glasgow and Clyde and NHS Grampian via leaflets or posters in clinic waiting areas; writing to those attending forthcoming clinics, or by staff on clinic attendance.
All participants had had insomnia for at least six months – with a group median of 30 months – and a quarter had suffered insomnia for more than five years. Two-thirds reported unrelenting insomnia.
Cognitive Behavioural Therapy (CBT) delivery
CBT was delivered by oncology nurses with no sleep medicine experience to testify the potential of CBT itself and to the feasibility of the treatment roll out. CBT addresses insomnia by dealing with the behavioural and mental factors that prevent people getting a normal sleep. It corrects faulty thinking, overcomes sleep-related worry and re-establishes a healthy sleep pattern without needing to use medication.
Nurse therapists attended a 12-hour two-day course on sleep disorders working with groups, CBT principles and instruction of the CBT program. Therapists sat in on existing CBT groups and maintained an informal peer support network. An experienced psychologist with training in behavioural sleep medicine acted as a mentor/consultant to the therapists but didn’t work directly with participants. The nurse-delivered CBT is part of a stepped care model designed to introduce effective treatment for insomnia that could become readily available on a widespread basis, with the back of expert clinical psychologists who could see people who have a more complex or resistant form of insomnia.
Summary of qualitative reports from patients
- CBT helped me get discipline and get my sleep into a proper pattern.
- There are still nights I don’t sleep but I don’t worry about it as much.
- I found restricting the sleep I have helpful because I know I’m not going to be lying awake for hours.
- Following the sleep program helped me cope with my young family and my disease although I continue to have daytime naps,
- my night-time quality of sleep has improved.
- My friends have noticed a change in my behaviour since I’ve been sleeping better.
Information for people recovering from cancer
Visit your GP if you are having sleep problems. Insomnia does affect people with cancer, for reasons not always related to treatment. Many people with cancer find they can’t sleep at times because they are worrying about their disease or treatment.
People often have chemotherapy with steroids, either as part of the treatment or to help with sickness. Steroids often cause sleep disturbance and might be better taken in the morning. With depression, you often go off to sleep but wake very early and can’t get back to sleep.
Once persistent insomnia develops it is a disorder that is largely self-perpetuating, like a vicious cycle of poor sleep, anxiety about sleep and its consequences and further poor sleep.
If you are depressed, the first choice of treatment is cognitive behaviour therapy designed to tackle your low mood or a course of antidepressants may help. If you are in pain, speak to your doctor, who can get the pain sorted out.
Anyone affected by cancer can contact Cancer Research UK’s cancer information nurses on 0808 800 4040 (freephone) or visit the charity’s patient information website www.cancerhelp.org.uk
University of Glasgow
Founded in 1451, the University of Glasgow is one of the top 100 universities in the world with an international reputation for its research and teaching and an important role in the cultural and commercial life of the country.
The University of Glasgow Sleep Centre was established by Professor Colin Espie as part of the Sackler Institute of Psychobiological Research in the Faculty of Medicine. It is a leading world centre for research into the causes and treatment of insomnia. It is located at the Southern General Hospital in the south of the city. The principal researcher on this study was Dr Leanne Fleming. Visit the Sleep Centre website for more information.
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