Clinical reviewSleep disturbance interventions in oncology patients and family caregivers: A comprehensive review and meta-analysis
Introduction
Recent evidence suggests that sleep disturbance is a significant problem associated with cancer and its treatment. Indeed, approximately 30–50% of oncology patients experience disrupted sleep in one form or another, a prevalence rate that exceeds that of the general population (12–25%).1 In the context of cancer, higher levels of sleep disturbance are associated with other deleterious symptoms (including fatigue, pain, and depression),2, 3 and have a negative impact on a number of patient-reported outcomes, including daily functioning and quality of life (QOL).4, 5 Notably, circadian rhythm dysregulation, potentially caused by disrupted sleep, has been linked to increased cancer incidence, as well as to disease progression and poorer prognosis, potentially mediated by dysregulation of the neuroendocrine system.6
Interestingly, the prevalence of sleep disturbance in family caregivers (FCs) of oncology patients is remarkably similar to the patients.*7, *8 This finding is not surprising considering the significant amount of stress placed on the FC, who may be overwhelmed by both escalating responsibility and the threat of losing a loved one. Moreover, sleep disturbance in FCs has similar negative effects on their functional status and QOL.9
Clearly, the magnitude and impact of sleep disturbance in oncology patients and their FCs provide evidence that this symptom warrants effective interventions in order to reduce symptom burden, improve QOL, and facilitate cancer survival. However, only a limited number of studies have evaluated the efficacy of interventions to manage sleep disturbance designed for both the patient and the FC.
The primary purposes of this review are to synthesize the findings from intervention studies for sleep disturbance in oncology patients and their FCs; to evaluate the efficacy of these interventions; to identify gaps in the literature; and to provide directions for future research.
Section snippets
Literature search strategy
A thorough review of the literature was performed using PubMed, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), and PsycINFO® databases from the earliest date available to 2010, as well as an evaluation of reference lists from 3 published reviews.*10, *11, *12 Search terms included “sleep”, “sleep disturbance”, “insomnia”, “intervention”, “cancer”, “oncology”, and “caregivers” in all applicable combinations. All intervention studies that evaluated sleep disturbance/sleep
Results and synthesis
As shown in Fig. 1, the vast majority (96%) of sleep disturbance intervention studies were conducted after the year 2000. This graph clearly demonstrates that the field of sleep disturbance intervention research is still in its infancy.
CBT interventions
CBT for insomnia is typically conducted in groups or one-on-one. It is commonly comprised of three components: cognitive components such as cognitive restructuring or reframing of negative or maladaptive thoughts and expectations about sleep; behavioral components including stimulus control (to re-associate the bed/bedroom with sleep); sleep restriction (to limit time in bed to sleep time), and relaxation (to reduce arousal), and an educational component referred to as sleep hygiene, that
Mode of delivery
The mode of delivery of the interventions varied widely, from purely written instructions by mail to intensive face-to-face sessions with an oncology nurse or licensed psychologist. Eight of the 47 (17%) studies did not specify the mode of delivery. Professionals included licensed psychologists, nurses, exercise physiologists, massage therapists, and other “therapists.” Interestingly, the highest proportion of studies with positive findings occurred among interventions delivered by members of
Dose and duration
The total maximum dose and duration of the reviewed interventions that explicitly reported these parameters (N = 37) are displayed in Fig. 3. An evaluation of the interventions revealed highly variable doses that ranged from 12 min to 70 h. Strikingly, a substantial proportion of studies (16 of 37; 43%) evaluated interventions that were of 5 h or less (see Fig. 3A). Because sleep disturbance is such a complex, troubling, and generally chronic symptom, it seems unreasonable to expect an
Sample size
Sample sizes for the reviewed intervention studies varied widely, with a range of 9–276 participants. Fig. 4 displays the frequency distribution for increasing sample size ranges. Notably, nearly half of the studies evaluated fewer than 50 participants, thus limiting the generalizability of the study findings. Moreover, only a small proportion (∼20%) of studies evaluated more than 100 participants. This sample size translates to roughly 50 participants per arm of an equally balanced two-arm
Type and comprehensiveness of sleep measures
The choice of measures used to assess sleep disturbance and sleep quality was highly variable across the 47 reviewed studies. However, three measures emerged as the ones used most frequently. The combination of these may be considered the gold standard for the assessment of sleep disturbance in oncology patients (Fig. 7A). Of note, the combination of these measures, the PSQI, the structured sleep diary, and wrist actigraphy, were typically employed by intervention studies that evaluated sleep
Study design and control groups
Roughly one-third (15 of 47) of the reviewed studies used a one-group pre-post or repeated measures design, as shown in Fig. 8A. Many of these were pilot, feasibility studies. Six studies (13%) used non-randomized or quasi-experimental designs with two or more groups. More than half (26 of 47; 55%) were RCTs. Six of these RCTs were 3-armed, the majority of which assessed two experimental groups, in addition to a control group. Due to small sample size in one pilot RCT that used a delayed
Interventions that target the family caregiver (FC)
Interestingly, and perhaps not surprisingly, moderate to severe sleep disturbance commonly occurs in oncology patients’ FCs.*7, *9 This symptom has similar impacts on functional status and QOL for this population,83 yet remains a virtually unexplored avenue of research. Indeed, in comparison with the 47 intervention studies targeting oncology patients, only 2 intervention studies, to our knowledge, were conducted with sleep as an outcome measure for the FCs.83, 84
Carter’s intervention,83 the
Conclusions and directions for future research
Although it is clear that consideration has been given to sleep disturbance in oncology patients, there is a dearth of research specifically devoted to improving sleep quality in both patients and their FCs. Only limited evidence is available on the efficacy of one intervention type over another, although this meta-analysis showed overall moderately clinically significant improvements in sleep disturbance in oncology patients. However, findings from the studies reviewed herein are complicated
Acknowledgments
D.J.L. is supported by a Canadian Institutes of Health Research (CIHR) Fellowship. C.M. is supported by grants from the National Institutes of Health and the American Cancer Society. A special thanks to Dr. Steven Paul for helpful statistical discussion. No conflicts of interest to declare.
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