Sleep disorders, such as difficulty falling asleep, problems maintaining sleep, poor sleep efficiency, early awakening, and excessive daytime sleepiness, are prevalent in patients with cancer. Such problems can become chronic in some patients, persisting for many months or years after completion of cancer therapy. For patients with cancer, sleep is potentially affected by a variety of factors, including the biochemical changes associated with the process of neoplastic growth and anticancer treatments, and symptoms that frequently accompany cancer, such as pain, fatigue, and depression.Fatigue is highly prevalent and persistent in patients with cancer and cancer survivors. Although cancerrelated fatigue and cancer-related sleep disorders are distinct, a strong interrelationship exists between these symptoms, and a strong possibility exists that they may be reciprocally related. The majority of studies that have assessed both sleep and fatigue in patients with cancer provide evidence supporting a strong correlation between cancer-related fatigue and various sleep parameters, including poor sleep quality, disrupted initiation and maintenance of sleep, nighttime awakening, restless sleep, and excessive daytime sleepiness. This paper reviews the data from these studies with a view toward suggesting further research that could advance our scientific understanding both of potential interrelationships between sleep disturbance and cancer-related fatigue and of clinical interventions to help with both fatigue and sleep disturbance. The Oncologist 2007;12(suppl 1): [35][36][37][38][39][40][41][42]

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Introduction Chronic pain is difficult to treat and often precedes or exacerbates sleep disturbances such as insomnia. Insomnia, in turn, can amplify the pain experience. Both conditions are associated with inflammatory processes, which may be involved in the bidirectional relationship between pain and sleep. Cognitive behavioral therapy (CBT) for pain and CBT for insomnia are evidence based interventions for, respectively, chronic pain and insomnia. The study objectives were to determine the feasibility of combining CBT for pain and for insomnia and to assess the effects of the combined intervention and the stand alone interventions on pain, sleep, and mood outcomes compared to a control condition. Methods Twenty-one adults with co-occurring chronic pain and chronic insomnia were randomized to either CBT for pain, CBT for insomnia, combined CBT for pain and insomnia, or a wait-list control condition. Results The combined CBT intervention was feasible to deliver and produced significant improvements in sleep, disability from pain, depression and fatigue compared to the control condition. Overall, the combined intervention appeared to have a strong advantage over CBT for pain on most outcomes, modest advantage over both CBT for insomnia in reducing insomnia severity in chronic pain patients. Discussion CBT for pain and CBT for insomnia may be combined with good results for patients with co-occurring chronic pain and insomnia.

To date very little research has been conducted on night-to-night variability in the incidence of insomnia. Unclear from prior research is whether subjects with Primary Insomnia (PI) exhibit good sleep (or better than average sleep) on some interval basis. In the present study, pilot data are provided on 1) the frequency with which “good sleep” occurs in subjects with PI and 2) whether these events occur in a non-random manner. 10 PI subjects participated in this “naturalistic” study. All subjects completed daily sleep diaries for a minimum of 20 days. None of the subjects received treatment for their insomnia during the monitoring period. The night-tonight data were evaluated by typing each night’s sleep as “Good” or “Bad” and then by determining the number of bad nights that occurred prior to a good night for each subject. Good and bad nights were typed in two ways: 1. using a ≥ 85% cutoff and 2. using a better than the individual’s mean sleep efficiency (idiographic cutoff). Subjects exhibited good sleep on between 29% (> 85% criteria) and 55% (idiographic criteria) of the nights evaluated. The temporal patterning analysis (based on a idiographic cutoff) revealed that better than average sleep most frequently occurred (> 89% of instances) following one to three night’s of poor sleep. These data suggests that insomnia severity may be mediated/moderated by sleep homeostasis and that the homeostat, or input to the homeostat, may be abnormal in patients with Primary Insomnia.

The purpose of this study was to assess the long-term (six months) effects of cognitive behavioral therapy for insomnia (CBT-I) in patients with chronic pain. The results of the pre-post treatment effects have been reported previously. The therapy was delivered by an advanced practice nurse in a research setting using a parallel-group, randomized, single blind trial of CBT-I with a contact/measurement control condition. Outcomes included sleep diary, the Insomnia Severity Index, the Multidimensional Pain Inventory, the Beck Depression Inventory, the Profile of Mood States-short form, and the Pain Disability Index. Measurement time points were end-of-treatment, three-month and six-month posttherapy. Subjects receiving CBT-I (n = 19), as compared to control subjects (n = 9), did not exhibit any significant group by visit effects on measures of sleep, pain, mood, or function after end of treatment. However, subjects in the treatment group exhibited statistically (P = 0.03) and clinically significant improvement in total sleep time (23 minutes) over the six months following treatment. In this paper, cognitive behavioral therapy directed to improve insomnia was successfully delivered to patients with moderate-to-severe chronic pain and the positive effects of CBT-I continued to improve despite the presence of continued moderate-to-severe pain.