Cancer centers providing care for adolescent and young adult cancer survivors may consider committing resources to routinely screen for sleep disorders and to support patient access to evidence-based insomnia treatment.
Eric Zhou, PhD
Results from a trial (NCT03279055) evaluating the Sleep Healthy Using the Internet (SHUTi) program, an internet-delivered cognitive-behavioral therapy for insomnia (CBT-I) revealed that the intervention was efficacious among adolescent and young adult (AYA) cancer survivors.1,2
It was previously noted that CBT-I was designed for adults and not adapted to the unique medical, psychological, and developmental needs of AYA cancer survivors, but the data revealed that significant improvements in insomnia severity, daytime sleepiness, fatigue, and quality of life were reported by AYA cancer survivors at both follow up time points.
The trial contained 22 AYA cancer survivors (mean age 20.4; range 14—25) with insomnia enrolled in the SHUTi program that was modified for AYA cancer survivors following stakeholder feedback. Although the program was shown to be efficacious, 72.7% of the study participants did not complete all of the 6 study sessions, with a mean completion rate of 3.2 sessions.
For those who did completed at least 2 sessions (n = 15), their insomnia severity index (ISI) scores decreased 5.1 points between baseline to first follow-up and decreased 10.0 points from baseline to second follow-up. Those who completed at least 3 sessions (n = 12) saw their ISI score decrease from baseline by 7.5 points at follow-up 1 and by 10.9 points at follow-up 2.
The first week of sleep diaries collected by SHUTi-AYA during session 2 showed an average participant sleep efficacy of 80.3%, which is clinically indicative of insomnia. This improved throughout the intervention, culminating in a sleep efficacy of 90.9% in session 6.
Christopher Recklitis, PhD, MPH, director of Research and Support Services, Perini Family Survivors Center, Dana-Farber Cancer Institute, said in a statement, “Notably, our participants' insomnia severity continued to get better after the intervention had ended, suggesting that the continued to make sleep-related decisions that helped their sleep even after they had finished using the program.”
Overall, 54.5% of cancer survivors had blood cancer and 45.5% of survivors were solid tumor, with an average of 9.7 years postdiagnosis. Eight of the 22 enrolled participants (36.4%) reported they were taking a medication for sleep (clonazepam, mirtazapine, hydroxyzine, melatonin, and diphenhydramine). End points such as sleep health, fatigue, and quality of life were assessed at baseline and at 8 and 16 weeks postbaseline.
SHUTi consists of 6, 20- to 30-minute sessions, and shows how sleep habits that may have helped patients cope with their intensive cancer treatments can become obstacles to healthy sleep as survivors move beyond treatment. The program consists of text, images, and video to explain how insomnia develops and how it can be overcome. During the study, patients would keep a sleep diary that logged when they slept, and was then transferred into SHUTi, which adjusted its sleep recommendations accordingly.
The program, which was developed by researchers at the University of Virginia, was adapted for AYA by Recklitis and Eric Zhou, PhD, staff psychologist, Dana-Farber Cancer Institute. Recklitis and Zhou used brief stories of individuals with younger age, rather than ones from the original version, to allow AYA survivors to relate closer.
"During treatment, people may stay in bed because they're not feeling well or haven't gotten enough sleep. They may take naps and their sleep at night can be fragmented,” Zhou stated. As people begin to move to the recovery phase, these habits can make it difficult to resume to healthy sleep patterns.
Results of this study hold critical implications for access to evidence-based clinical care in this growing population. Additionally, future studies that focus on stepped care models of care and ways to improve treatment adherence were recommended.
1. Online program improves insomnia in adolescent and young adult cancer survivors [news release]. Dana-Farbar Cancer Institute. Published June 22, 2020. Accessed June 26, 2020. eurekalert.org/pub_releases/2020-06/dci-opi062120.php
2. Zhou ES, Recklitis CJ. Internet-delivered insomnia intervention improves sleep and quality of life for adolescent and young adult cancer survivors. Pediatr Blood Cancer. Published online June 22, 2020. doi: 10.1002/pbc.28506.