Cognitive behavioral interventions are designed to reflect concepts from cognitive behavioral therapy, which examines the association among thoughts, feelings, and behaviors. Cognitive behavioral interventions do not involve full cognitive behavorial psychotherapy; however, they do assist patients in identifying negative or unhelpful thoughts and beliefs to change them. Cognitive behavioral intervention approaches also help individuals to identify helpful and unhelpful behaviors, establish goals, and develop skills to solve problems and implement new behaviors to facilitate effective coping. Structured programs based on cognitive behavioral approaches may include activities such as education or relaxation training, may be provided in individual or group settings, and may be delivered in person, telephonically, or by other methods. Cognitive behavioral therapy approach interventions for sleep are aimed specifically at assisting patients to change sleep behaviors and reduce sleep disturbance.
Larkin, D., Lopez, V., & Aromataris, E. (2013). Managing cancer-related fatigue in men with prostate cancer: A systematic review of non-pharmacological interventions. International Journal of Nursing Practice.
STUDY PURPOSE: To review the published evidence on non-pharmacologic interventions for fatigue in men with prostate cancer
TYPE OF STUDY: Meta-analysis and systematic review
DATABASES USED: PubMed, PsycINFO, CINAHL, Cochrane Central Trials Register and Embase, PsychExtra, SIGLE, Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, World Health Organisation International Clinical Trials Registry Platform, EU Clinical Trials Register, MedNar, and reference lists of articles included in review
KEYWORDS: key concepts of prostate cancer, fatigue, non-pharmacological and nursing management, and various interventions; detailed search for PubMed included as appendix
INCLUSION CRITERIA: Adult men older than 18 years with prostate cancer at any stage of treatment; non-pharmacologic interventions including exercise, exercise with diet and lifestyle modification, education, and cognitive behavioral therapy; comparison to other non-pharmacologic interventions or usual care; experimental studies; fatigue as primary outcome of interest using existing validated tools to measure
EXCLUSION CRITERIA: Not stated
TOTAL REFERENCES RETRIEVED = 1,480
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Two independent reviewers appraised studies; validity assessed with Johanna Briggs Institute Critical Appraisal Checklist for Randomised and Pseudo-Randomised Studies
PHASE OF CARE: Multiple phases of care
APPLICATIONS: Elder care
All studies were of high methodologic quality. Four out of five studies measuring physical activity found statistically significant fatigue reduction; the other study showed a trend toward fatigue reduction. Two studies concluded that cognitive behavioral therapy was effective in managing cancer-related fatigue. Two studies looking at education had mixed results. Brief nursing education was not significant in reducing fatigue, but intensive prostate-specific education was significant.
This report supports physical activity for managing cancer-related fatigue. Cognitive behavioral therapy and intensive focused education are also likely to be effective.
Nurses should continue to recommend physical activity for management of cancer-related fatigue. Cognitive behavioral therapy and intensive education may be considered.
Tang, N.K., Lereya, S.T., Boulton, H., Miller, M.A., Wolke, D., & Cappuccio, F.P. (2015). Nonpharmacological treatments of insomnia for long-term painful conditions: A systematic review and meta-analysis of patient-reported outcomes in randomized controlled trials. Sleep, 38, 1751–1764.
STUDY PURPOSE: To evaluate the effects of nonpharmacologic interventions on patient-reported sleep, pain, and well-being in people with cancer and other conditions
TYPE OF STUDY: Meta-analysis and systematic review
PHASE OF CARE: Not specified or not applicable
All treatments had at least one component of cognitive behavioral therapy for insomnia. Subgroup analysis showed that the interventions tested were significant for both cancer and noncancer cases. Another subgroup analysis showed that effectiveness was significant for face-to-face interventions but not for those conducted via the phone or Internet. Analysis showed effects for sleep (standard mean difference [SMD] = 0.78, p < 0.0001 with high heterogeneity), pain (SMD = 0.18, p = 0.05), and fatigue (SMD = 0.38, p = 0.01).
Nonpharmacologic interventions involving components of cognitive behavioral therapy for insomnia were shown to be effective in improving sleep, pain, and fatigue among patients with and without cancer.
High heterogeneity
Interventions like cognitive behavioral for insomnia are beneficial to improve sleep, reduce fatigue, and positively affect pain.
Barsevick, A., Beck, S. L., Dudley, W. N., Wong, B., Berger, A. M., Whitmer, K., . . . Stewart, K. (2010). Efficacy of an intervention for fatigue and sleep disturbance during cancer chemotherapy. Journal of Pain and Symptom Management, 40, 200–216.
To evaluate the efficacy of an energy and sleep enhancement (EASE) intervention to relieve fatigue and sleep disturbance and improve health-related functional status.
One hundred fifty-three individuals receiving chemotherapy were randomized to the EASE intervention and 139 were randomized to an attention control intervention. Participants in each group received three telephone sessions taught by a specially trained oncology nurse and a separate written handbook for each assigned intervention. The EASE intervention was based on the common sense model and involved appraisal and representation of symptoms, with a focus on fatigue and sleep disturbance, including communication of individualized strategies for fatigue management and sleep enhancement. The control intervention focused on information about nutrition and a healthy diet. The primary outcomes of fatigue, sleep disturbance, and functional status were measured before chemotherapy, day 4 after first treatment (baseline), and 43 to 46 or 57 to 60 days later (follow-up), depending on the chemotherapy cycle length. Two secondary outcomes, pain and depression, were chosen for evaluation, but not targeted for the intervention, because of an increasing body of evidence linking them to fatigue.
Patients were undergoing the active treatment phase of care.
This was a randomized, controlled trial using repeated measures and an attention control.
Fatigue and patient-reported sleep disturbance were moderately elevated in both groups at baseline and follow-up. Actigraphy revealed that the total sleep time was almost eight hours, and sleep efficacy was in the normal range of greater than 85% for both groups at both time points. Physical functioning was diminished and at the same level as a sample with serious illness. Mental functioning was in the normal range. The EASE intervention did not improve fatigue, reduce sleep disturbance, or prevent functional decline during chemotherapy. Both the EASE intervention group and the control group had an increase in fatigue and decline in physical functioning over time. ANOVA revealed no statistically significant group-by-time effects for fatigue, sleep disturbance, or functional status. A positive outcome in both groups was a decrease in the average number of nighttime awakenings over time. Unemployed individuals showed greater benefit from the EASE intervention and reported less pain and symptom interference.
In patients with cancer undergoing chemotherapy, the EASE intervention did not significantly improve fatigue, sleep disturbance, or physical functioning compared to the control group. Potential explanations include high variability or floor effect for fatigue, incorrect timing of measures, insufficient amount or dose of the intervention, and confounding effects of gender. Future research should consider screening for symptom severity and tailoring interventions.
Future research directions were clearly described in the study, and practice implications included: many individuals with multiple symptoms during chemotherapy could benefit from effective behavioral interventions conducted over time by skilled nurses. Further research could inform nurses of the most effective management methods to control symptoms.
Berger, A. M., Kuhn, B. R., Farr, L. A., Lynch, J. C., Agrawal, S., Chamberlain, J., & Von Essen, S. G. (2009). Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. Psycho-oncology, 18, 634–646.
To determine the effectiveness of a behavioral therapy (BT) intervention, an individualized sleep promotion plan (ISPP), on sleep quality and fatigue in women with breast cancer receiving adjuvant chemotherapy.
Participants were recruited and screened for eligibility between 2003 and 2006. Eligible women interested in participation were visited by a research nurse who completed the randomization procedure, administered baseline questionnaires, and had patients wear an actigraph two days prior to the initial treatment. The intervention was delivered by research nurses who were trained by a sleep psychologist.
Those assigned to the BT group developed a 120-item ISPP with the research nurse according to the nurse's review of responses to measures to identify areas of sleep difficulty. Advice and information was tailored to individual needs. Revisions to the ISPP were made in 30-minute appointments made with participants two days prior to each treatment and 30 days after the last treatment. Reinforcement of the plan was made in 15-minute appointments seven days after each revision. Each ISPP included
Patients in the control group received equal time and attention at each home visit and were provided with general support and a discussion of a new healthy eating topic.
Multisite
This was a randomized, controlled study.
Baseline sleep quality measures indicated mild fatigue, somewhat poor sleep quality, low levels of symptom distress, and normal anxiety and depression levels. PSQI scores indicated lower sleep quality than the general adult population but better scores than those previously associated with poor sleep quality in patients with breast cancer. There were significant differences over time on all sleep variables from the diaries and actigraphs (p < 0.01). Diaries showed a significantly lower number of awakenings (p = 0.032), a lower average amount of time awake while in bed (p = 0.027), and higher sleep efficiency (p = 0.001) in the BT group. Fatigue scores in both groups increased during treatment and decreased after treatment ended (p < 0.0001). This pattern was similar in both study groups. Perceived fatigue was similar between the two groups. There was a trend of improved sleep quality over time (PSQI) in the BT group.
The four-component ISPP was associated with improved sleep quality over time, better sleep efficiency, and fewer awakenings. Findings suggested that perceptions of improved sleep quality were not consistently associated with diary entries or objective sleep measures.
Berger, A. M., Kuhn, B. R., Farr, L. A., Von Essen, S. G., Chamberlain, J., Lynch, J. C., & Agrawal, S. (2009). One-year outcomes of a behavioral therapy intervention trial on sleep quality and cancer-related fatigue. Journal of Clinical Oncology, 27, 6033–6040.
To determine the effects of a behavioral therapy (BT) sleep intervention (individualized sleep promotion plan [ISPP]) on cancer-related fatigue over a one-year period in women receiving adjuvant chemotherapy for breast cancer.
Patients at each study site were stratified according to number of planned anthracycline-based treatments and good versus poor sleep quality. Patients were then randomly assigned to the ISPP group or a control group that received care regarding health eating (HEC), which received the same amount of individual time and attention as the ISPP group. At baseline, patients in the ISPP group spent 90 minutes with the research nurse to develop a 12-item ISPP plan. Two days before all treatments, they spent another 30 minutes with the research nurse revising the plan based on sleep diaries and plan adherence data. After each revision, plans were reinforced in a 15-minute, in-person session seven to nine days after the revision. Plans included
Thirty-minute sessions were held to revise the BT plan again at 30, 60, and 90 days after the last chemotherapy treatment. HEC participants received in-person sessions of equal time and attention before each treatment and at 30, 60, and 90 days after the completion of chemotherapy.
This was a randomized, controlled trial with a one-year follow-up.
The BT group had a significant improvement in sleep quality compared to the HEC group at 90 days (p = 0.002) but not at one year (p = 0.052). Higher fatigue (p = 0.027) and higher anxiety (p = 0.012) at baseline were associated with poorer sleep at one year. There were no differences in most diary and objective sleep findings at selected times over the year. Sleep diary and actigraph findings did not coincide for either group. Values recorded in the diaries tended to show better sleep time and percent and lower numbers of awakenings than the actigraph findings. Moderate to severe fatigue was reported at one year by 20% of patients in the BT group and 24% in the HEC group. Fatigue changed over time for both groups, but there were no significant differences between the groups. PSQI scores over time were significantly better in the BT group (p = 0.013).
The BT intervention improved global sleep quality but did not improve fatigue in women over a period of one year. Baseline anxiety was associated with higher fatigue and poor sleep at one year.
Berger, A. M., VonEssen, S., Kuhn, B. R., Piper, B. F., Agrawal, S., Lynch, J. C., & Higginbotham, P. (2003). Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: results of a feasibility intervention study. Oncology Nursing Forum, 30, 513–522.
Patients received a multi-component, cognitive-behavioral therapy (CBT), individual sleep promotion plan (ISPP) that included
The ISPP started two days before the first prescription; continued during chemotherapy prescription; was revised 30, 60, and 90 days after the last prescription; and was reinforced seven days later. There were three doses and reinforcements.
Patients were undergoing the long-term follow-up phase of care.
This was a prospective, repeated measures, feasibility study with a single group and no control.
Adherence to the intervention was high except for stimulus control. Fatigue scores were not significantly different over time.
Berger, A. M., VonEssen, S., Khun, B. R., Piper, B. F., Farr, L., Agrawal, S., . . . & Higginbotham, P. (2002). Feasibility of a sleep intervention during adjuvant breast cancer chemotherapy. Oncology Nursing Forum, 29, 1431–1441.
Patients received multicomponent cognitive-behavioral therapy (CBT). Individual sleep promotion plans (ISPPs) included
Each plan started two days before the first prescription, was revised before each prescription, and was and reinforced seven days after each prescription. There were four doses and reinforcements.
Patients were undergoing the active treatment phase of care.
This was a prospective, repeated measures, feasibility study with a single group and no control.
Casault, L., Savard, J., Ivers, H., & Savard, M.H. (2015). A randomized-controlled trial of an early minimal cognitive-behavioural therapy for insomnia comorbid with cancer. Behaviour Research and Therapy, 67, 45–54.
To examine the efficacy of an early minimal cognitive behavioral therapy (CBT) intervention for insomnia in patients with cancer
The treatment consisted of self-help CBT provided with written materials and three phone consultations. Participants completed a quiz after each booklet was read and were asked to maintain a daily sleep diary. Control patients did not receive any intervention. The study was conducted over six weeks. Study measures were obtained at baseline, at the end of six weeks, and three and six months later. Participants were paid after each assessment was completed.
Randomized, controlled trial
There were significant effects over time by study group on ISI scores in favor of the CBT intervention at six weeks (p < 0.001), and there were improvements in all sleep variables with effect sizes (d) ranging from 0.46–1.34. Control patients also showed improvements. There were no significant changes from the six-week to six-month time point in either group. Those in the CBT group had a reduction in hypnotic dosage (d = 0.40). There were significant improvements in anxiety scores (p < 0.001) in the CBT group at six weeks. Depression declined significantly in both groups. No significant effect on fatigue was found. A greater proportion of CBT patients achieved a sleep efficiency level greater than or equal to 85% (p = 0.01). More than 97% of patients completed the materials, and 91.2% completed the quiz on average.
The brief CBT intervention used here was effective in improving insomnia and anxiety among patients with cancer.
CBT interventions are effective in treating sleep–wake disturbances and psychological issues. This study demonstrated that the provision of a CBT approach via booklets and quizzes on the CBT for sleep content with follow-up and counseling by phone was an effective way to deliver the intervention. Although this sample size was small, it did approximate the size required from a power analysis. This approach to providing a CBT intervention can be practical and cost-effective. However, significant effects were only seen during the active study period, and effects were not shown to endure long-term.
Cohen, M., & Fried, G. (2007). Comparing relaxation training and cognitive-behavioral group therapy for women with breast cancer. Research on Social Work Practice, 17, 313–323.
To compare the effectiveness of a cognitive-behavioral therapy (CBT) group intervention versus a relaxation and guided imagery (RGI) group training intervention.
The intervention groups received nine 90-minute weekly sessions, and the control group received standard care. The outcomes measured were psychological distress, sleep, fatigue, and health locus of control.
Oncology center in northern Israel
Patients were undergoing the active treatment phase of care.
This was a randomized, controlled trial.
GSI and perceived stress decreased in both intervention groups but not in the control group. Means of fatigue symptoms and sleep difficulties decreased in both intervention groups but only significantly in the RGI group. External health locus of control decreased more in the CBT group. No differences were observed among groups in internal locus of control. Participants in the RGI group reported significantly higher self-practice adherence at home than did those in the CBT group.
A study design with four groups—CBT, RGI, combined CBT and RGI, and control—could shed light on whether combining CBT and RGI is more advantageous than delivering either intervention individually.
Davidson, J. R., Waisberg, J. L., Brundage, M. D., & MacLean, A. W. (2001). Nonpharmacologic group treatment of insomnia: a preliminary study with cancer survivors. Psycho-oncology, 10, 389–397.
Participants received multimodal cognitive-behavioral group therapy in six 1- to 1.5-hour sessions, given weekly x5 and then repeated in four weeks. Therapy included stimulus control therapy, relaxation training, sleep consolidation strategies, and strategies to reduce cognitive-emotional arousal.
Outpatient clinics at Major Cancer Center in Central Canada and the community serving the Cancer Center, Midwestern Canada
This was a repeated measure, single-group design with no control group.
Fatigue significantly decreased at week eight in comparison to baseline. Values of sleep, mood, and functioning improved from baseline, to four weeks, and to eight weeks after the intervention. Improved sleep measures included
Dirksen, S. R., & Epstein, D. R. (2008). Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. Journal of Advanced Nursing, 61, 664–675.
The intervention was delivered by a master’s prepared nurse and consisted of four weekly classes and two weeks of treatment conducted through individual weekly telephone sessions. Each class followed a standard format using a treatment manual. The cognitive-behavioral therapy (CBT) intervention consisted of stimulus control instructions, sleep restriction therapy, sleep education, and hygiene content, including cognitive strategies. The aim of the stimulus control interventions was to shape cognitions to reassociate the bed and bedroom with rapidly falling asleep or falling back to sleep. The aims of stimulus control were to acquire a consistent sleep pattern, strengthen the bed and bedroom as cues for sleep, and weaken them as cues for activities that interfere with sleep. Sleep restriction therapy was based on the observation that people with insomnia spend too much time in bed attempting to sleep. The treatment focused on developing a sleep-wake schedule that consolidates sleep and limits it to a specific time by restricting the amount of time spent in bed. Sleep education and hygiene consisted of giving basic information about sleep processes and functions, developmental sleep changes, circadian rhythms, individual sleep needs, sleep deprivation, and supportive information. Dysfunctional cognitions that may contribute to sleep difficulty were also challenged.
This was a randomized, controlled trial with assignment to either CBT for insomnia or a control group that received education about sleep and sleep hygiene.
Profile of Mood States Fatigue/Inertia Subscale (POMS-F/I)
Women in the intervention group demonstrated significantly lower fatigue compared to those in the control group. The authors concluded that because mediation analyses indicated that the intervention had no direct effect on any of the psychosocial outcomes, that the intervention had an indirect effect on the outcome of fatigue due in part to improvements in sleep quality (both groups demonstrated improvements in mean scores for insomnia severity across the course of the study, and in a study reported elsewhere, they also demonstrated significant improvements in other sleep outcome indicators and favorable changes in actigraphy).
A modest amount of continuing education, as well as access to some instructional materials for patients, are needed to prepare health care professionals to deliver CBT interventions for insomnia.
Espie, C. A., Fleming, L., Cassidy, J., Samuel, L., Taylor, L. M., White, C. A., . . . & Paul, J. (2008). Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer. Journal of Clinical Oncology, 26, 4651–4658.
Nurses administered a cognitive-behavioral therapy (CBT) intervention consisting of five weekly 50-minute sessions provided during early afternoon or early evening. The intervention included standard CBT components, such as stimulus control, sleep restriction, and cognitive therapy strategies. The nurses had participated in CBT courses and psychologist-supervised practice and had audiotapes from randomly selected sessions evaluated for congruence with intervention components and principles.
Participants were randomized to either receive CBT or treatment as usual, with stratification for center, prerandomization Pittsburgh Sleep Quality Index (PSQI) scores, existing treatment for insomnia, and tumor type. A 2:1 treatment allocation, in favor of the intervention, was selected to make efficient use of the available CBT sessions and minimize the time patients would have to wait for CBT, thus reducing the potential for patient dropout. Researchers used several strategies to promote intervention fidelity and the integrity of the treatment allocations: the study staff did not interact with other patients in the treatment as usual group, clinicians working with participants in the treatment as usual group did not receive any information about CBT; and printed intervention materials were developed.
This was a randomized, controlled, pragmatic, two-center trial of CBT.
Fatigue Symptom Inventory Interference Subscale
Compared with usual care, CBT resulted in a statistically significant improvement in fatigue interference/daytime fatigue following CBT treatment, and these improvements were sustained at six-month follow-up. Two-thirds of CBT participants attended all therapy sessions, and 94% attended at least three of five CBT sessions. There were similar levels of attrition in the intervention (18%) and usual-care comparison (16%) groups.
Neither interventionists nor patients were blinded to study group allocation, and participants' knowledge that they were assigned to particular treatment arms may have influenced their responses on patient-reported outcome measures.
Fleming, L., Randell, K., Harvey, C.J., & Espie, C.A. (2014). Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Psycho-Oncology.
To explore relationships among variables and evaluate change in symptoms following cognitive behavioral therapy for insomnia (CBTI)
This paper reports a secondary analysis of a randomized controlled trial of CBTI delivered in group sessions over five weeks. Assessments done at baseline and post-treatment were analyzed.
PHASE OF CARE: Transition phase after active treatment
Secondary analysis of a randomized controlled trial
The most common symptom cluster reported was insomnia, anxiety, and fatigue (18% of patients). Clinical-level insomnia was reduced by 52% in the CBTI group compared to a 17.5% reduction in the usual care controls post-intervention (p < .001). CBTI resulted in a 10.9% reduction in rate of clinical levels of fatigue, compared with a 2.5% increase in control patients post-treatment (p = .03). Anxiety rates did not change. Most patients were not clinically depressed at baseline, and no significant differences were seen between groups in depression rates post-intervention.
The CBTI reduced prevalence of insomnia and clinically relevant fatigue.
Findings support the use of CBTI for sleep/wake disturbance and fatigue management in patients after cancer treatment. Follow-up in this report was immediately after five weeks of the intervention only, so how long-lasting any effects are is not clear.
Heckler, C.E., Garland, S.N., Peoples, A.R., Perlis, M.L., Shayne, M., Morrow, G.R., . . . Roscoe, J.A. (2016). Cognitive behavioral therapy for insomnia, but not armodafinil, improves fatigue in cancer survivors with insomnia: A randomized placebo-controlled trial. Supportive Care in Cancer, 24, 2059–2066.
To assess the combined and comparative effect of cognitive behavioral therapy (CBT) and armodafinil to improve sleep and daytime functioning in survivors of cancer.
Participants were randomized to (a) CBT-I and placebo, (b) CBT-I and armodafinil 50 mg b.i.d., (c) placebo BID, or (d) armodafinil 50 mg BID. All received written sleep hygiene guidelines. Participants had CBT-I in 30–60-minute individual, in-person sessions during weeks 1, 2, and 4; and had 15–30-minute phone sessions during weeks 3, 5, and 7. Study medicine was taken for 47 days from 7 am to 9 am and 12 pm to 2 pm.
Improvement in fatigue was noted with CBT for insomnia (p = 0.002 on BFI; p < 0.001 on FACIT-F). No improvement in fatigue was noted with placebo, on armodafinil alone, or on armodafinil with CBT-I.
CBT for insomnia appears to improve fatigue in patients with insomnia, and armodafinil was not shown to improve fatigue in patients with insomnia and fatigue.
This study shows that CBT for insomnia may be beneficial to patients with fatigue and that armodafinil does not improve fatigue.
Matthews, E.E., Berger, A.M., Schmiege, S.J., Cook, P.F., McCarthy, M.S., Moore, C.M., & Aloia, M.S. (2014). Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: A randomized, controlled trial. Oncology Nursing Forum, 41, 241–253.
To examine the effect of cognitive behavioral therapy (CBT) on sleep-wake outcomes in breast cancer survivors
Women who met criteria for chronic insomnia and had completed breast cancer treatment randomly were assigned to CBT intervention or a placebo behavioral intervention. Individual, weekly CBT sessions consisted of education, stimulus control, sleep hygiene education, and cognitive therapy provided by an advanced practice nurse with specialized training. The placebo intervention was based on desensitization therapy that had been used in previous insomnia trials as a placebo treatment. For both groups, sessions 1, 3, and 6 were provided in person, and sessions 4 and 5 were provided by telephone. Sessions were audiotaped and independently reviewed by a CBT therapist to ensure fidelity. Women were evaluated at three- and six-month follow-ups.
The CBT group did not show a significantly greater improvement in sleep outcomes immediately after the intervention, but scores were significantly better by the follow-up period (p = .003). Sleep efficiency increased by more than 11% in the CBT group, compared to an increase of 6.34% in the control group (d = 0.63). Sleep latency also improved more in the CBT group (d = 0.48, p = .007). No differences between groups were found for anxiety, depression, or fatigue.
Findings show that patients receiving CBT for sleep improved several sleep outcomes compared to individuals receiving a control intervention. The intervention did not demonstrate an effect on anxiety, depression, or fatigue.
Results of this study provide evidence of a moderate and significant effect of CBT on sleep outcomes among breast cancer survivors. This adds to the body of evidence that suggests effectiveness of this approach in managing sleep-wake disturbances.
Prinsen, H., Bleijenberg, G., Heijmen, L., Zwarts, M. J., Leer, J. W., Heerschap, A., . . . van Laarhoven, H. W. (2013). The role of physical activity and physical fitness in postcancer fatigue: a randomized controlled trial. Supportive Care in Cancer, 21, 2279–2288.
To examine the effect of cognitive-behavioral therapy (CBT) on fatigue and to examine whether the effect on fatigue is mediated by physical activity and/or physical fitness.
Patients referred for CBT were randomly assigned to the intervention group or to a wait-list control group. The CBT intervention was provided in six modules focusing on coping, rear of disease recurrence, dysfunctional cognitions related to fatigue, activity management, dysregulation of sleep, social support, and negative social interactions. Material was adapted to the individual patients. All patients set a baseline level of physical activity and, once set, began an activity program of cycling or walking five to 10 minutes twice daily. This was increased to a maximum of 120 minutes daily. Study measures were obtained at baseline and six-month follow-up. Physical activity was measured for two weeks prior to study entry.
Patients were undergoing the late effects and survivorship phase of care.
This was a randomized, controlled trial.
Forty-six percent of patients in the intervention were lost to follow-up. The CBT group had a significantly greater improvement in fatigue scores than control patients (p < 0.001). There was significantly greater improvement in functional impairment in the CBT group compared to controls (p = 0.009). Fatigue and impairment improved over the six-month period in both groups. There were no significant differences between groups in physical activity or physical fitness measures at baseline or follow-up. Analysis showed no mediation effect of physical activity or physical fitness.
Findings suggested that CBT was effective in reducting cancer-related fatigue and sickness impact scores. Findings suggested that this effect was not mediated by physical activity or fitness.
Findings supported the potential effectiveness of CBT for fatigue management in cancer care. These findings were in patients about four years after completion of treatment, suggesting benefits even long after active treatment. There were several study limitations that reduced the strength of this evidence.
Quesnel, C., Savard, J., Simard, S., Ivers, H., & Morin, C. M. (2003). Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer. Journal of Consulting and Clinical Psychology, 71, 189–200.
Patients received multimodal cognitive-behavioral therapy (CBT) that combined cognitive, behavioral, and educational strategies. Treatment consisted of eight weekly sessions administered in a group of five participants combined with use of stimulus control, sleep restriction, cognitive therapy, sleep hygiene, and fatigue and stress management. The treatment protocol was based on clinical procedures developed by Morin (1993) and adapted by the investigators for the cancer population.
Ten breast cancer survivors participated in this pilot study.
Patients were included in the study if they
Patients who regularly used psychotropic medications other than hypnotics were excluded unless the dosage use was stable in the last month and did not increase during the study. Individuals currently receiving psychotherapy were also excluded.
Patients were undergoing the long-term follow-up phase of care.
This was a single-arm study with no control group.
Multidimensional Fatigue Inventory (MFI)
Nonparametric statistical testing revealed significant improvements in the general and physical subscales of the MFI; there was no significant change between pre- and posttreatment on the mental, activities, and motivation subscales of the MFI. There was no significant change observed from posttreatment through six-month follow-up on the MFI general and physical subscales, suggesting that the treatment gains were sustained over time.
Savard, J., Ivers, H., Savard, M.H., & Morin, C.M. (2014). 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. Sleep, 37, 1305–1314.
To test the short-term efficacy of a video-based delivery of cognitive behavioral therapy for insomnia compared to a professionally administered method and a no-treatment group
Patients with breast cancer postradiation therapy who were 18 months post-treatment with insomnia were randomized into one of three groups: a video-based cognitive behavioral therapy intervention (VB-CBTI) (60 minute video with six booklets), a professionally delivered CBTI (six weekly, 50-minute, in-person sessions), or a no-treatment group.
Randomized, controlled, three-arm intervention study
Group-by-time interactions were significant for sleep variables with video-based CBTI being associated with greater sleep improvements compared to the control group for sleep variables other than early-morning awakening and total sleep time (p < 0.001). There were no significant differences between in-person and video-based CBTI for sleep onset latency, wake after sleep onset, total wake time, and sleep efficiency. In-person treatment was associated with a greater reduction in ISI scores, early morning awakening, and total wake time compared to video-based CBTI. The magnitude of change over time was greater with in-person CBTI compared to video CBTI. Both interventions demonstrated a greater improvement in sleep outcomes than the control group. Actigraphy showed a significant reduction (pre/post) in the in-person group only. Secondary outcomes among the in-person group included a significant reduction in depression (p < 0.001), fatigue (p < 0.001), and dysfunctional beliefs about sleep (p < 0.001).
Both CBTIs were effective in improving sleep compared to usual care. The video format seems to be an effective treatment option, but in-person therapy continues to show better efficacy. CBTI also was associated with improvements in fatigue and depression scores.
CBTIs can be challenging to implement because access to care for patients with cancer is varied. Although in-person therapy was most effective, the video-based intervention also was effective in improving sleep, fatigue, and depression outcomes. Providing options to rural populations without access to in-person care is essential for increasing efficacy in a wider population with insomnia. The findings of this study regarding the efficacy of a video-based CBTI provide nurses with another option that warrants its use as a treatment with longer effects.
Savard, J., Simard, S., Giguère, I., Ivers, H., Morin, C. M., Maunsell, E., . . . Marceau, D. (2006). Randomized clinical trial on cognitive therapy for depression in women with metastatic breast cancer: psychological and immunological effects. Palliative and Supportive Care, 4, 219–237.
The cognitive-behavioral therapy (CBT) intervention for insomnia consisted of eight weekly sessions of approximately 90 minutes, offered in groups of four to six patients, and delivered by a clinical psychologist. The treatment protocol was multimodal and combined behavioral (e.g., stimulus control therapy, sleep restriction), cognitive (i.e., cognitive restructuring), and educational (i.e., sleep hygiene, fatigue and stress management) strategies that were described in a treatment manual given to all participants. A booster session was offered to participants one month after the end of treatment. Missed treatment sessions were rescheduled; therefore, all patients received the entire treatment program. Outcomes were evaluated at the conclusion of the intervention, as well as at three, six, and 12 months after the end of treatment.
Fifty-seven women with stage I to III breast cancer who met the diagnostic criteria for a chronic insomnia syndrome (CBT group, n=27; comparison group, n=30) were included.
Diagnostic criteria included
Only patients whose insomnia was judged to be secondary to cancer were included in the study (i.e., those whose sleep difficulties were caused or aggravated by the cancer diagnosis or treatment). Most of the sample had received prior adjuvant treatment with radiation therapy (85.2%), chemotherapy (37%), or hormone therapy (59.3%). Slightly more than one-third of the sample was currently receiving hormone therapy (37%).
Exclusion criteria included severe major depression or other serious psychiatric disorder; presence of a sleep disorder other than insomnia (e.g., sleep apnea), presence of another illness affecting the immune system (e.g., human immunodeficiency virus [HIV] infection), and regular use of a psychotropic medication other than hypnotics (e.g., antidepressants) unless the dosage used was stable in the last month and did not increase during the study; and current involvement in psychotherapy.
Patients were undergoing the active treatment phase of care.
This was a randomized, controlled trial, with patients randomly assigned to CBT for insomnia or a wait-list control group.
Multidimensional Fatigue Inventory (MFI)
Analysis of pooled data revealed a statistically significant improvement in fatigue from pre- to posttreatment, with maintenance of this improvement during the 12-month follow-up period.
Savard, J., Simard, S., Ivers, H., & Morin, C. M. (2005). Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. Journal of Clinical Oncology, 23, 6083–6096.
Patients received multimodal cognitive-behavioral therapy (CBT) that combined cognitive, behavioral, and educational strategies. Treatment consisted of eight weekly sessions administered in a group of four to six participants and was combined with use of stimulus control, sleep restriction, cognitive therapy, sleep hygiene, and fatigue and stress management. The treatment protocol was based on clinical procedures developed by Morin (1993) and was adapted by the investigators for the cancer population.
Fifty-seven breast cancer survivors were randomly assigned to a CBT (n=27) or waiting list condition (n=30).
Patients were included in the study if they
Patients who regularly used psychotropic medications other than hypnotics (e.g., antidepressants) were excluded unless the dosage use was stable in the last month and did not increase during the study. Individuals currently receiving psychotherapy were also excluded.
Patients were undergoing the long-term follow-up phase of care.
This was a randomized, controlled trial with a waiting list control group and a 12-month follow-up period to assess the short- and long-term effects of the intervention.
Multidimensional Fatigue Inventory (MFI)-French Canadian version to measure fatigue
Pooled analyses within an intent-to-treat framework revealed significant differences between pre- and posttreatment on fatigue (p < 0.001). No significant difference was detected between posttreatment and the three-, six-, and 12-month evaluations of fatigue, suggesting that the clinical improvement relative to the outcome of fatigue was durable.
It is not possible to determine whether the improvements in fatigue observed in this study are attributable to the CBT strategies or to other ingredients common to all psychotherapeutic approaches (e.g., therapist empathy, group support). Sustained improvements in fatigue may also be a result of a maturation effect wherein fatigue declined as might be expected, with greater distance from treatment.
Vargas, S., Antoni, M.H., Carver, C.S., Lechner, S.C., Wohlgemuth, W., Llabre, M., . . . Derhagopian, R.P. (2013). Sleep quality and fatigue after a stress management intervention for women with early-stage breast cancer in Southern Florida. International Journal of Behavioral Medicine. Retrieved from http://link.springer.com/article/10.1007%2Fs12529-013-9374-2
10-week CBSM
No statistical differences in PSQI total scores or changes in fatigue intensity between groups. Changes in sleep quality were associated with change in fatigue.
CBSM may have some positive effects on elements of sleep quality and fatigue. Data support an association between sleep quality and fatigue (fatigue-related daytime interference).
Consider evaluation of sleep disturbance in patients experiencing fatigue.
Bower, J.E., Bak, K., Berger, A., Breitbart, W., Escalante, C.P., Ganz, P.A., . . . American Society of Clinical Oncology. (2014). Screening, assessment, and management of fatigue in adult survivors of cancer: An American Society of Clinical Oncology clinical practice guideline adaptation. Journal of Clinical Oncology, 32, 1840–1850.
PHASE OF CARE: Late effects and survivorship
Adapted from three guidelines by multidisciplinary experts using supplementary evidence and clinical experience. Most recommendations listed verbatim but some modified to include updated evidence or current practice beliefs.
Recommendations focused on patients who have completed active treatment or are considered in clinical remission. Treat underlying causes, moderate physical activity after cancer treatment with PT and lymphedema referrals as needed (meta-analysis, systematic review, [randomized controlled trial [RCT]; 10 cited), cognitive behavioral therapy (meta-analysis, RCT, systematic reviews; 6 cited), psychoeducational therapies (systematic, RCT; 3 cited), psychosocial services, mindfulness-based interventions (RCT; 3 cited), yoga (RCT; 2 cited), acupuncture (RCT; 2 cited), psychostimulants/wakefulness agents (limited evidence in patients who are post-treatment disease-free). Additional areas in which research needed include biofield therapies, massage, music therapy, relaxation, Reiki, Qigong, ginseng, and vitamin D.
Guidelines were tailored to survivors with current evidence as not all evidence done is survivors.
Screening, assessment, and treatment guidelines summarized for use in cancer survivors.
National Comprehensive Cancer Network. (2016). NCCN Clinical Practice Guidelines in Oncology: Cancer-related fatigue [v.1.2016]. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/fatigue.pdf
PHASE OF CARE: Multiple phases of care
Two hundred two references were retrieved. The total number of references included and reviewed for updating was not provided. No quality rating is identified.
The guidelines provide suggestions for screening and identify some tools for fatigue assessment and some key interventions for the management of fatigue. They provide an overview of relevant evidence for multiple types of interventions. Major suggestions are identified in the recommendations section of this summary.