Assessing the Feasibility of a Multi-modal Intervention for Sleep Disturbances in Patients With Advanced Cancer

Advances in cancer treatments have improved prognosis for many patients, placing a heightened demand on clinical care to provide quality of life as well as quantity of life. Individuals with advanced cancer face progressive symptoms that are a major source of suffering and impairment. Sleep disturbance is a prevalent, but often overlooked symptom, affecting up to 96% of patients with advanced cancer. While there are multiple types of sleep disorders affecting patients with advanced cancer, insomnia seems to be the most prevalent sleep disorder in this patient cohort, occurring at various points in the patient's disease and treatment trajectory. Adequate sleep is essential for maintaining normal function and overall existence. Inadequate sleep may further compound illness and impair recovery. Sleep disturbances are associated with fatigue, accidents/injuries, anxiety and depression, cognitive impairment and delirium and immunosuppression. In addition, sleep disturbance is associated with aberrant patterns of cortisol secretion, which can impair the cellular immunity responsible for mounting a defence against tumours. Pharmacotherapy is the most common treatment for sleep disturbances, despite the numerous associated adverse effects and absence of empirical evidence of their efficacy and innocuity in this patient population. Multiple studies have recognised that patients with advanced cancer are at an increased risk of harm induced by medications due to age, polypharmacy and co-morbidities that can alter pharmacodynamics. Yet, despite the evidence of harmful effects of hypnotics and the lack of evidence to support their use, they are routinely prescribed as first-line treatment for the management of sleep disturbances in patients with advanced cancer.

Cognitive behavioural therapy for insomnia (CBT-I) is considered the non-pharmacological first-line treatment to manage insomnia in adults. CBT for insomnia includes various components that helps the patient to learn coping skills and ways to prevent or mitigate the severity of future episodes.

Both bright white light therapy and exercise have proven to be successful non-pharmacological methods of optimising daytime activity, improving sleep duration and enhancing symptoms and quality of life in patients with cancer.

Study interventions

1. CBT-I is a first-line treatment for insomnia. The online course consists of four CBT-I sessions and allows the individual to complete one module per week in the comfort of their own home. Online CBT-I has been shown to be as effective as face-to-face CBTI. CBT-I covers cognitive and behavioural aspects to understand sleep processes and improve sleep duration and quality.
2. Bright light therapy has been shown to be effective at improving night-time sleep and daytime physical activity. It is delivered from a light box. The participants will be advised to sit near the light box for 30 minutes each morning. Participants can continue with other activities, such as eating breakfast, whilst sitting with the light box.
3. An individualised physical activity plan will be created to encourage increased daytime physical activity and reduced daytime sedentary behaviour. Existing physical activity levels will be considered, any barriers to physical activity addressed, and goals for physical activity set. These will be reviewed on a weekly basis and adjusted as appropriate. For example, if goals are easily being achieved, further activity increases will be advised. If the patient struggles to meet goals, their goal will be lowered. Patients will be provided with a generic watch activity tracker to help them to monitor their progress.