Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Efficacy of an intervention for fatigue and sleep disturbance during cancer chemotherapy. Tailoring cognitive-behavioral treatment for cancer pain. Randomized controlled pilot trial of mindfulness-based stress reduction compared to psychoeducational support for persistently fatigued breast and colorectal cancer survivors Sleep Disturbances in Patients With Advanced Cancer in Different Palliative Care Settings. Impact of mindfulness-based stress reduction (MBSR) on sleep, mood, stress and fatigue symptoms in cancer outpatients A Pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer Individual Psychosocial Support for Breast Cancer Patients: A Randomized Study of Nurse Versus Psychologist Interventions and Standard Care Mindfulness based stress reduction in post-treatment breast cancer patients: an examination of symptoms and symptom clusters The efficacy of mindfulness-based stress reduction in the treatment of sleep disturbance in women with breast cancer: an exploratory study. Effect of Melatonin on Cognitive Function and Sleep in relation to Breast Cancer Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial Cognitive behavioural treatment for women who have menopausal symptoms after breast cancer treatment (MENOS 1): a randomised controlled trial Research and commentary: Change in exercise tolerance, activity and sleep patterns, and quality of life in patients with cancer participating in a structured exercise program. Teaching head and neck cancer patients coping strategies: results of a feasibility study. Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Long-Term Effects of Two Formats of Cognitive Behavioral Therapy for Insomnia Comorbid with Breast Cancer. Effects of exercise on fatigue, physical functioning, and emotional distress during radiation therapy for breast cancer. A Randomized Trial of Aerobic Exercise and Sleep Quality in Lymphoma Patients Receiving Chemotherapy or No Treatments 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. Augmentation of venlafaxine and selective serotonin reuptake inhibitors with zolpidem improves sleep and quality of life in breast cancer patients with hot flashes: a randomized, double-blind, placebo-controlled trial The effects of mindfulness-based stress reduction on objective and subjective sleep parameters in women with breast cancer: a randomized controlled trial. Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors. Attribution, cognition and psychopathology in persistent insomnia disorder: outcome and mediation analysis from a randomized placebo-controlled trial of online cognitive behavioural therapy. Effect of exercise on biomarkers, fatigue, sleep disturbances, and depressive symptoms in older women with breast cancer receiving hormonal therapy. Effects of exercise on fatigue, sleep, and performance: a randomized trial. The Efficacy of Oral Melatonin in Improving Sleep in Cancer Patients with Insomnia: A Randomized Double-Blind Placebo-Controlled Study Does cognitive behaviour therapy for insomnia reduce clinical levels of fatigue, anxiety and depression in cancer patients? Feasibility of Exercise During Treatment for Multiple Myeloma Sleep Quality and Fatigue after a Stress Management Intervention for Women with Early-Stage Breast Cancer in Southern Florida Cancer Rehabilitation: Outcome Evaluation of a Strengthening and Conditioning Program Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: Sleep and psychological effects. Nonpharmacologic group treatment of insomnia: a preliminary study with cancer survivors. Effects of exercise dose and type on sleep quality in breast cancer patients receiving chemotherapy: a multicenter randomized trial Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Cognitive behavioral therapy for insomnia, but not armodafinil, improves fatigue in cancer survivors with insomnia: a randomized placebo-controlled trial A home-based exercise program to improve function, fatigue, and sleep quality in patients with Stage IV lung and colorectal cancer: a randomized controlled trial. Initial evaluation of an Internet intervention to improve the sleep of cancer survivors with insomnia. A randomized, placebo-controlled trial of melatonin on breast cancer survivors: impact on sleep, mood, and hot flashes Feasibilty of a sleep intervention during adjuvant breast cancer chemotherapy. Exercise, sleep quality, and mediators of sleep in breast and prostate cancer patients receiving radiation therapy. Effect of walking on circadian rhythms and sleep quality of patients with lung cancer: a randomised controlled trial Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial. Impact of a home-based walking intervention on outcomes of sleep quality, emotional distress, and fatigue in patients undergoing treatment for solid tumors. Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress and levels of cortisol, dehydroepiandrosterone sulfate (DHEAS) and melatonin in breast and prostate cancer outpatients Adherence, sleep, and fatigue outcomes after adjuvant breast cancer chemotherapy: results of a feasibility intervention study. Cost-utility analysis of individual psychosocial support interventions for breast cancer patients in a randomized controlled study. The longitudinal relationship between fatigue and sleep in breast cancer patients undergoing chemotherapy. Individual cognitive behavioral therapy for insomnia in breast cancer survivors: a randomized controlled crossover pilot study. Exercise intervention for fatigue-related symptoms in Thai women with breast cancer: A pilot study. Comparison of psychosocial outcomes in head and neck cancer patients receiving a coping strategies intervention and control subjects receiving no intervention. Biobehavioral factors mediate exercise effects on fatigue in breast cancer survivors. A randomized-controlled trial of an early minimal cognitive-behavioural therapy for insomnia comorbid with cancer. Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. Rating the quality of evidence for clinical practice guidelines. The Comparative Impact of Mindfulness-Based Cancer Recovery (MBCR) and Cognitive Behavior Therapy for Insomnia (CBT-I) on Sleep and Mindfulness in Cancer Patients. Effect of Melatonin on Sleep in the Perioperative Period after Breast Cancer Surgery: A Randomized, Double-Blind, Placebo-Controlled Trial. Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial. Effect of mindfulness-based stress reduction on sleep quality: Results of a randomized trial among Danish breast cancer patients
INTRODUCTION The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults , when such treatment is clinical ly indicated . Unlike previous meta-analyses , which focused on broad classes of drugs , this guideline focuses on individual drugs commonly used to treat insomnia . It includes drugs that are FDA -approved for the treatment of insomnia , as well as several drugs commonly used to treat insomnia without an FDA indication for this condition . This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults . METHODS The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine . A systematic review was conducted to identify r and omized controlled trials , and the Grading of Recommendations Assessment , Development , and Evaluation ( GRADE ) process was used to assess the evidence . The task force developed recommendations and assigned strengths based on the quality of evidence , the balance of benefits and harms , and patient values and preferences . Literature review s are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations . The AASM Board of Directors approved the final recommendations . RECOMMENDATIONS The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults , when such treatment is indicated . Under GRADE , a STRONG recommendation is one that clinicians should , under most circumstances , follow . A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients , but should not be construed as an indication of ineffectiveness . GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient , but rather , to the strength of evidence in published data . Downgrading the quality of evidence for these treatments is predictable in GRADE , due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias ; the relatively small number of eligible trials for each individual agent ; and the observed heterogeneity in the data . The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient , available diagnostic tools , accessible treatment options , and re sources . We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use triazolam as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  diphenhydramine  as a treatment for sleep onset and sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  melatonin  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) . We suggest that clinicians not use  valerian  as a treatment for sleep onset or sleep maintenance insomnia ( versus no treatment ) in adults . ( WEAK ) CONTEXT Multiple complex symptoms from cancer treatment can interfere with functioning . OBJECTIVES To evaluate the efficacy of an " energy and sleep enhancement " ( EASE ) intervention to relieve fatigue and sleep disturbance and improve health-related functional status . METHODS Individuals receiving chemotherapy ( CTX ) were r and omized to the EASE ( n=153 ) or a control intervention ( n=139 ) . The EASE intervention included information and behavioral skills taught by an oncology nurse in three telephone sessions . The primary outcomes of fatigue , sleep disturbance , and functional status were measured before CTX , Day 4 after first treatment ( baseline ) , and 43 - 46 or 57 - 60 days later ( follow-up ) , depending on the CTX cycle length . RESULTS The sample was primarily female ( 82 % ) and non-Hispanic white ( 89 % ) , with mean age of 53.9 years .  Fatigue and patient-reported sleep disturbance were elevated in both groups at baseline and follow-up . Actigraphy revealed that the total sleep time was almost eight hours , and sleep percent was greater than 85 % for both groups at both time points ( normal range ) . Physical functioning was diminished and at the same level as a sample with serious illness . Mental functioning was in normal range . A repeated- measures analysis of variance revealed no statistically significant group-by-time effects for fatigue , sleep disturbance , or functional status .  Unemployed individuals showed greater benefit from the EASE intervention , reporting less pain and symptom interference . CONCLUSION Potential explanations include high variability and /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 Though it has been shown that cancer patients report cognitive , behavioral , and physiologic responses to pain , little attention has been paid to the benefits of cognitive-behavioral therapy ( CBT ) protocol s tailored to patient characteristics . To determine whether a profile-tailored CBT treatment program was more effective than either st and ard CBT or usual care in changing outcomes for patients with cancer-related pain , 131 patients receiving treatment at four sites were r and omly assigned to st and ard CBT , profile-tailored CBT , or usual care . CBT patients attended five 50-minute treatment sessions . When compared to st and ard CBT patients , profile-tailored CBT patients experienced substantial improvement from baseline to immediately post-intervention in worst pain , least pain , less interference of pain with sleep , and less confusion . From baseline to one-month post-intervention , profile-tailored patients saw greater improvement in less interference of pain with activities , walking , relationships , and sleep ; less composite pain interference ; and less mobility and confusion symptom distress .  St and ard CBT and usual care patients experienced little change . Compared to profile-tailored CBT patients , st and ard CBT patients showed greater improvement at six-months post-intervention with less average pain , less pain now , better bowel patterns , lower summary symptom distress , better mental quality of life , and greater improvement in Karnofsky performance status ; usual care patients showed little change . More research is needed to refine the matching of cognitive-behavioral treatments to psychophysiologic patient profiles , and to determine a treatment period that does not burden those patients too fatigued to participate in a five-week program . Delivery of CBT by home visits , phone , or Internet needs to be explored further Purpose Cancer-related fatigue ( CRF ) is a disruptive symptom for many survivors . Despite promising evidence for efficacy of mindfulness-based stress reduction ( MBSR ) in reducing CRF , no trials comparing it to an active comparator for fatigued survivors have been published . The purpose of this trial was to compare MBSR to psychoeducation for CRF and associated symptoms . Methods Breast ( n = 60 ) and colorectal ( n = 11 ) cancer survivors ( stage 0–III ) with clinical ly significant CRF after completing chemotherapy and /or radiation therapy an average of 28 months prior to enrollment were r and omized to MBSR or psychoeducation/support groups ( PES ) . MBSR focused on mindfulness training ; PES focused on CRF self-management . Outcomes included CRF interference ( primary ) , CRF severity and global improvement , vitality , depression , anxiety , sleep disturbance , and pain . Outcomes were assessed at baseline ( T1 ) , post-intervention ( T2 ) , and 6-month follow-up ( T3 ) using intent-to-treat analysis . Results Between-group differences in CRF interference were not significant at any time point ; however , there was a trend favoring MBSR ( d = −0.46 , p = 0.073 ) at T2 . MBSR participants reported significantly greater improvement in vitality ( d = 0.53 , p = 0.003 ) and were more likely to report CRF as moderately to completely improved compared to the PES group ( χ2 ( 1 ) = 4.1765 , p = 0.041 ) at T2 . MBSR participants also reported significantly greater reductions in pain at T2 ( d = 0.53 , p = 0.014 ) . In addition , both MBSR and PES produced moderate-to-large and significant within-group improvements in all fatigue outcomes , depression , anxiety , and sleep at T2 and T3 compared to T1 . Conclusion MBSR and PES appear efficacious for CRF and related symptoms . Larger trials including a usual care arm are warranted . Trial Registration Clinical Trials.gov Identifier : NCT01724333 CONTEXT Information regarding sleep disturbances in the population with advanced cancer is meager . OBJECTIVES To assess the prevalence of sleep disturbances and possible correlations with associated factors in a large number of patients with advanced cancer admitted to different palliative care setting s. METHODS This was an observational study performed in different setting s of palliative care . A consecutive sample of patients with advanced cancer was prospect ively assessed for a period of six months . Epidemiological and clinical data , treatments received in the last month , Karnofsky status , Edmonton Symptom Assessment System scores , and concomitant medical treatment were recorded . Patients were administered the  Athens Insomnia Scale and  the Hospital Anxiety and Depression Scale ( HADS ) .  RESULTS A total of 820 patients were surveyed . Mean age was 69.7 years ( SD 12.7 ) , and 429 patients were males . Consistent sleep disturbances ( moderate to maximum ) were found in 60.8 % of patients . Aged patients were less likely to have sleep disturbances , whereas a poor Karnofsky level was significantly associated with sleep problems . Breast , gastrointestinal , head and neck , lung , and prostate cancers were associated with sleep problems . Patients who had a secondary school or undergraduate education had less sleep disturbances .  Hormone therapy and use of opioids and corticosteroids were positively associated with sleep disturbances , and there was a positive correlation of HADS-Anxiety and HADS-Depression scores with sleep disturbances . CONCLUSION More than 60 % of  palliative care patients have relevant sleep disturbances . Several factors associated with sleep disorders have been identified and should prompt physicians to make a careful examination and subsequent treatment of these disturbances Sleep disturbance is a very common problem for cancer patients that has largely not been addressed in the clinical intervention literature . Mindfulness meditation has demonstrated clinical benefits for a variety of patient population s in other areas of functioning . This study examined the effects of an 8-week Mindfulness-Based Stress Reduction ( MBSR ) program on the sleep quality of a heterogeneous sample of 63 cancer patients . Overall sleep disturbance was significantly reduced ( p < .001 ) and participants reported that their sleep quality had improved ( p < .001 ) . There was also a significant reduction in stress ( p < .001 ) , mood disturbance ( p = .001 ) , and fatigue ( p < .001 ) . The associations among these changes and implication s for improving quality of life of cancer patients are discussed Purpose This study aims to provide recommendations on the optimal strategies and interventions for the prevention , screening , assessment , and management of  cancer-related sleep disturbance ( insomnia and insomnia syndrome ) in adult cancer population s. Methods A systematic search of the published health literature was conducted to identify r and omized controlled trials , clinical practice guidelines , systematic review s , and other guidance documents . The Sleep Disturbance Expert Panel [ comprised of nurses , psychologists , primary care physicians , oncologists , physicians specialized in sleep disturbances , research ers , and guideline method ologists ] review ed , discussed , and approved the final version of the guideline . Health care professionals across Canada were asked to provide feedback through an external review process . Results Three clinical practice guidelines and 12 r and omized controlled trials were identified as the evidence base . Overall , despite the paucity of evidence , the evidence and expert consensus suggest that it is important to screen and assess adult cancer patients for sleep disturbances using st and ardized screening tools on a routine basis . While prevention of sleep disturbance is the desired objective , cognitive behavioral therapies are effective in improving sleep outcomes . As part of the external review with 16 health care providers , 81 % indicated that they agreed with the recommendations as written . Conclusions Sleep difficulty is a prevalent problem in cancer population s that needs greater recognition by health professionals . Prevention , screening , assessment , and treatment strategies supported by the best available evidence are critical . Recommendations and care path algorithms for practice are offered In a prospect i ve , r and omized study , an individual psychosocial support intervention performed by specially trained oncology nurses , or psychologists , were compared with st and ard care .  Consecutive primary breast cancer patients about to start adjuvant therapy ( n = 179 ) were included . Data were supplied by the question naires European Organisation for Research and Treatment of Cancer Quality of Life Study Group Core Quality of life question naire with 30 questions ( EORTC QLQ-C30 ) and Breast Cancer Module with 23 questions ( BR23 ) , the Hospital Anxiety and Depression Scale , Spielberger 's State-Trait Anxiety Inventory , and the Impact of Event Scale before r and omization and 1 , 3 , and 6 months later . Patient files provided data on utilization of psychosocial support offered in routine care . Global quality of life/health status , nausea and vomiting , and systemic therapy side effects were the subscales showing significant Group by Time interactions , favoring the interventions . Intervention groups improved statistically significantly more than the st and ard care group regarding insomnia , dyspnea , and financial difficulties . Nurse patients experienced less intrusion compared with the st and ard care group . All groups showed statistically and clinical ly significant improvements with time on several subscales . The intervention groups , however , improved to a greater extent . Fewer patients in the intervention groups used psychosocial hospital support compared with the st and ard care group . In conclusion , psychosocial support by specially trained nurses using techniques derived from cognitive behavioral therapy is beneficial for breast cancer patients and may be a realistic alternative in routine cancer care To investigate prevalence and severity of symptoms and symptom clustering in breast cancer survivors who attended MBSR(BC ) .  Women were r and omly assigned into MBSR(BC ) or Usual Care ( UC ) . Eligible women were ≥ 21 years , had been diagnosed with breast cancer and completed treatment within 18 months of enrollment . Symptoms and interference with daily living were measured pre- and post-MBSR(BC ) using the M.D. And erson Symptom Inventory . Symptoms were reported as highly prevalent but severity was low . Fatigue was the most frequently reported and severe symptom among groups . Symptoms clustered into 3 groups and improved in both groups . At baseline , both  MBSR(BC ) and the control groups showed similar mean symptom severity and interference ; however , after the 6-week post-intervention , the MBSR(BC ) group showed statistically-significant reduction for fatigue and disturbed sleep ( P < 0.01 ) and improved symptom interference items , compared to the control group . For the between-group comparisons , 11 of 13 symptoms and 5 of 6 interference items had lower means in the MBSR(BC ) condition than the control condition . These results suggest that MBSR(BC ) modestly decreases fatigue and sleep disturbances , but has a greater effect on the degree to which symptoms interfere with many facets of life . Although these results are preliminary , MBSR intervention post-treatment may effectively reduce fatigue and related interference in QOL of breast cancer survivors OBJECTIVE The diagnosis of breast cancer , the most common type of cancer among American women , elicits greater distress than any other diagnosis regardless of prognosis . Therefore , the present study examined the efficacy of a stress reduction intervention for women with breast cancer . METHODS As part of a larger , r and omized , controlled study of the effects on measures of stress of a mindfulness-based stress reduction ( MBSR ) intervention for women with breast cancer , the current analyses examined the effects on sleep complaints . RESULTS Analyses of the data indicated that both MBSR and a free choice ( FC ) control condition produced significant improvement on daily diary sleep quality measures though neither showed significant improvement on sleep-efficiency . Participants in the MBSR who reported greater mindfulness practice improved significantly more on the sleep quality measure most strongly associated with distress . CONCLUSION MBSR appears to be a promising intervention to improve the quality of sleep in woman with breast cancer whose sleep complaints are due to stress Background . Sleep disturbances and cognitive dysfunction are common in patients with breast cancer . Disturbed sleep leads to poor cognitive performance and exogenous melatonin may improve sleep and attenuate cognitive dysfunction . We hypothesized that melatonin would improve sleep and cognitive function after surgery . Methods . This study reports secondary endpoints from a r and omized , double-blind , placebo-controlled trial . Women , 30–75 years , were r and omized to 6 mg oral melatonin/placebo for 3 months . We assessed postoperative cognitive dysfunction ( POCD ) with a neuropsychological test battery , sleep with a diary , and sleep quality with VAS . Results . 54 patients were r and omized to melatonin ( n = 28 ) or placebo ( n = 26 ) ; 11 withdrew ( 10 placebo , 1 melatonin , P = 0.002 ) . The incidence of POCD was 0 % ( 0/20 ) [ 95 % CI 0.0 % ; 16.8 % ] in the placebo group and 0 % ( 0/26 ) [ 95 % CI 0.0 % ; 13.2 % ] in the melatonin group 2 weeks postoperatively ( P = 1.00 ) and 6.3 % ( 1/16 ) [ 95 % CI 0.0 % ; 30.2 % ] in the placebo group and 0 % ( 0/26 ) [ 95 % CI 0.0 % ; 13.2 % ] in the melatonin group 12 weeks postoperatively ( P = 0.38 ) . Sleep efficiency was significantly greater in the melatonin group ; mean difference was 4.28 % [ 95 % CI 0.57 ; 7.82 ] ( P = 0.02 ) . The total sleep period was significantly longer in the melatonin group ; mean difference was 37.0 min [ 95 % CI 3.6 ; 69.7 ] ( P = 0.03 ) . Conclusion . Melatonin  increased sleep efficiency and total sleep time but did not affect cognitive function . The dropout rate was significantly lower in the melatonin group . This trial is registered with Clinical trials.gov NCT01355523 Summary Background Hot flushes and night sweats ( HFNS ) affect 65–85 % of women after breast cancer treatment ; they are distressing , causing sleep problems and decreased quality of life . Hormone replacement therapy is often either undesirable or contraindicated . Safe , effective non-hormonal treatments are needed . We investigated whether cognitive behavioural therapy ( CBT ) can help breast cancer survivors to effectively manage HFNS . Methods In this r and omised controlled trial , we recruited women from breast clinics in London , UK , who had problematic HFNS ( minimum ten problematic episodes a week ) after breast-cancer treatment . Participants were r and omly allocated to receive either usual care or usual care plus group CBT ( 1:1 ) . R and omisation was done in blocks of 12–20 participants , stratifying by age ( younger than 50 years , 50 years or older ) , and was done with a computer-generated sequence . The trial statistician and research ers collecting outcome measures were masked to group allocation . Group CBT comprised one 90 min session a week for 6 weeks , and included psycho-education , paced breathing , and cognitive and behavioural strategies to manage HFNS . Assessment s were done at baseline , 9 weeks , and 26 weeks after r and omisation . The primary outcome was the adjusted mean difference in HFNS problem rating ( 1–10 ) between CBT and usual care groups at 9 weeks after r and omisation . Analysis of the primary endpoint was done by modified intention to treat . The trial is registered , IS RCT N13771934 , and was closed March 15 , 2011 . Findings Between May 5 , 2009 , and Aug 27 , 2010 , 96 women were r and omly allocated to group CBT ( n=47 ) or usual care ( n=49 ) . Group CBT  significantly reduced HFNS problem rating at 9 weeks after r and omisation compared with usual care ( mean difference −1·67 , 95 % CI −2·43 to −0·91 ; p<0·0001 ) and improvements were maintained at 26 weeks ( mean difference −1·76 , −2·54 to −0·99 ; p<0·0001 ) . We recorded no CBT-related adverse events . Interpretation Group CBT seems to be a safe and effective treatment for women who have problematic HFNS after breast cancer treatment with additional benefits to mood , sleep , and quality of life . The treatment could be incorporated into breast cancer survivorship programmes and delivered by trained breast cancer nurses . Funding Cancer Research UK PURPOSE / OBJECTIVES To investigate the feasibility of an exercise program patterned after a phase II cardiac rehabilitation program to improve selected physiologic and psychological parameters of health in patients with cancer . DESIGN Prospect i ve , repeated measures study . SETTING Two major military medical centers in the southwestern United States . SAMPLE 62 patients diagnosed with cancer within the previous two years . Ages ranged from 24 - 83 ( meanX = 59 ) . Half of the participants were male and half were female . Minorities made up 29 % of the sample . Participants had a wide range of cancer diagnoses and all stages of cancer . Fifteen subjects were undergoing treatment when they enrolled in the study . More than half of the subjects exercised prior to their cancer diagnoses , but fewer than half were able to resume an exercise routine following their cancer diagnoses . METHODS Subjects met two days each week for 12 weeks for exercise and education . MAIN RESEARCH VARIABLES Exercise tolerance as measured with a grade d exercise test , activity and sleep patterns as measured with a wrist actigraph , and quality of life ( QOL ) as measured with the Cancer Rehabilitation Evaluation System-Short Form . FINDINGS Significant improvements were observed over time in exercise tolerance , selected activity and sleep patterns , and QOL among the 46 ( 74 % ) subjects who completed the program . CONCLUSIONS Patients with various types and stages of cancer can safely exercise using a cardiac rehabilitation model and can realize significant improvements in exercise tolerance , selected activity and sleep patterns , and QOL . IMPLICATION S FOR NURSING Most people are aware that regular exercise is part of a healthy lifestyle . After cancer diagnosis and treatment , patients experience uncertainty regarding how to resume exercise or how to begin an exercise program as part of their rehabilitation . Participation in a structured exercise program can provide patients with a safe environment within which to exercise at an intensity appropriate to their individual needs To test the feasibility of providing a psycho-educational intervention for people with head and neck ( H&N ) cancer . A prospect i ve non-r and omized design was used . Subjects were patients with H&N cancer . They were offered the Nucare coping strategies program in one of three formats : small group and one-to-one formats with therapists ; and a home format , with material for home use , without a therapist . Outcomes measures ( quality of life ( QOL ) and anxiety and depression ) were collected at baseline and following the intervention . Analyses were performed using non-parametric statistics . Of 128 people invited to participate , 66 agreed , 59 completed the intervention and 50 had outcomes data . Following the intervention , there were significant improvements in physical and social functioning and global QOL , and reduced fatigue , sleep disturbance and depressive symptoms . These data suggest that the intervention may have some beneficial effects , although an appropriately design ed study is required to confirm this PURPOSE / OBJECTIVES To evaluate the feasibility of a patient-controlled cognitive-behavioral intervention for  pain , fatigue , and sleep disturbance during treatment for advanced cancer and to assess initial efficacy of the intervention . DESIGN One group pre- and post-test design . SETTING Outpatient oncology clinics at a comprehensive cancer center in the midwestern United States . SAMPLE 30 adults with advanced ( recurrent or metastatic ) colorectal , lung , prostate , or gynecologic cancer receiving chemotherapy or radiotherapy . METHODS Participants completed baseline measures ( e.g. , demographics , symptom inventory ) and received education and training to use an MP3 player loaded with 12 cognitive-behavioral strategies ( e.g. , relaxation exercises , guided imagery , nature sound recordings ) . Participants used the strategies as needed for symptom management for two weeks , keeping a log of symptom ratings with each use . Following the two-week intervention , participants completed a second symptom inventory and an evaluation of the intervention . MAIN RESEARCH VARIABLES Feasibility , patient-controlled cognitive-behavioral intervention , pain , fatigue , and sleep disturbance . FINDINGS Thirty of 43 eligible patients ( 73 % ) agreed to participate ; of them , 27 ( 90 % ) completed the study . Most reported that they enjoyed the intervention , had learned useful skills , and perceived improvement in their symptoms . Symptom scores at two weeks did not differ significantly from baseline ; however , significant reductions in pain , fatigue , and sleep disturbance severity were found in ratings made immediately before and after use of a cognitive-behavioral strategy . CONCLUSIONS The patient-controlled cognitive-behavioral intervention appears to be feasible for additional study and could reduce day-to-day severity of co-occurring pain , fatigue , and sleep disturbance . IMPLICATION S FOR NURSING A r and omized , controlled trial is needed to test efficacy of the intervention for co-occurring pain , fatigue , and sleep disturbance . Meanwhile , based on previous efficacy studies , cognitive-behavioral strategies can be recommended for certain individual symptoms STUDY OBJECTIVES The goal of this r and omized controlled trial , conducted in breast cancer patients , was to assess the long-term efficacy of a video-based cognitive behavioral therapy for insomnia ( VCBT-I ) , as compared to a professionally administered intervention ( PCBT-I ) and to a no-treatment group ( CTL ) . An earlier report revealed that , at posttreatment , VCBT-I patients showed significantly greater sleep improvements than CTL , but that PCBT-I produced superior effects than VCBT-I on some sleep and secondary outcomes . In this report , long-term effects are compared . METHODS Two hundred forty-two women with breast cancer and with insomnia symptoms or using hypnotic medications participated to this three-arm r and omized controlled trial : ( 1 ) PCBT-I ( n = 81 ) ; ( 2 ) VCBT-I ( n = 80 ) ; or ( 3 ) no treatment ( CTL ; n = 81 ) group . PCBT-I was composed of six weekly , individual sessions of approximately 50 min , whereas VCBT-I comprised a 60-min animated video and six booklets . RESULTS Study measures ( sleep and secondary variables ) were administered at pretreatment and posttreatment , and at a 3- , 6- , and 12-mo follow-up . Treatment gains were well sustained at follow-up in both PCBT-I and VCBT-I. As at posttreatment , the remission rate of insomnia at follow-up was greater in PCBT-I than in VCBT-I , which was greater than in CTL . CONCLUSIONS Although face-to-face therapy remains the optimal format to efficaciously administer CBT for insomnia in cancer patients , a minimal intervention , such as the video-based intervention tested in this study , produces significant and sustainable treatment effects . CLINICAL TRIAL REGISTRATION Clinical Trials.gov identifier NCT00674830 PURPOSE S/ OBJECTIVES To test the hypothesis that women participating in a walking exercise program during radiation therapy treatment for breast cancer would demonstrate more adaptive responses as evidence d by higher levels of physical functioning and lower levels of symptom intensity than women who did not participate . DESIGN Experimental , two-group pretest , post-test . SETTING Two university teaching hospital outpatient radiation therapy departments . SAMPLE 46 women beginning a six-week program of radiation therapy for early stage breast cancer . METHODS Following r and om assignment , subjects in the exercise group maintained an individualized , self-paced , home-based walking exercise program throughout treatment . The control group received usual care . Dependent variables were measured prior to and at the end of radiation therapy . In addition , symptoms were assessed at the end of three weeks of treatment . MAIN RESEARCH VARIABLES Participation in the walking exercise program , physical functioning fatigue , emotional distress , and difficulty sleeping . FINDINGS Hypothesis testing by multivariate analysis of covariance , with pretest scores as covariates , indicated significant differences between groups on outcome measures ( p < 0.001 ) . The exercise group scored significantly higher than the usual care group on physical functioning ( p = 0.003 ) and symptom intensity , particularly fatigue , anxiety , and difficulty sleeping . Fatigue was the most frequent and intense subjective symptom reported . CONCLUSIONS A self-paced , home-based walking exercise program can help manage symptoms and improve physical functioning during radiation therapy . IMPLICATION S FOR NURSING PRACTICE Nurse-prescribed and -monitored exercise is an effective , convenient , and low-cost self-care activity that reduces symptoms and facilitates adaptation to breast cancer diagnosis and treatment Background : Patients with lymphoma experience sleep problems that may be managed with aerobic exercise but no previous study has examined this issue . Methods : We r and omized 122 patients with lymphoma to usual care ( n = 62 ) or 12 weeks of supervised aerobic exercise training ( AET ; n = 60 ) . Our primary sleep endpoint was global sleep quality assessed by the Pittsburgh Sleep Quality Index ( PSQI ) . Secondary endpoints were the PSQI component scores . Planned subgroup analyses were also conducted . Results : Intention-to-treat analyses indicated that AET result ed in a nonsignificant ( P = 0.16 ) improvement in global sleep quality compared with usual care [ mean group difference = −0.64 ; 95 % confidence interval ( CI ) , −1.56 to + 0.27 ] . In planned subgroup analyses , statistically significant or borderline significant interactions were identified for type of lymphoma ( Pinteraction = 0.006 ) , current treatment status ( Pinteraction = 0.036 ) , time since diagnosis ( Pinteraction = 0.010 ) , body mass index ( Pinteraction = 0.075 ) , and baseline sleep quality ( Pinteraction = 0.041 ) . Specifically , AET  improved global sleep quality in patients with lymphoma who had indolent non – Hodgkin lymphoma ( P = 0.001 ) , were receiving chemotherapy ( P = 0.013 ) , were < 2 years post-diagnosis ( P = 0.005 ) , were obese ( P = 0.025 ) , and were poor sleepers at baseline ( P = 0.007 ) . Conclusions : AET did not significantly improve sleep quality in this heterogeneous sample of patients with lymphoma ; however , clinical ly identifiable subgroups appeared to benefit . Future exercise trials targeting these responsive subgroups are needed to confirm these findings . Impact : If replicated in larger and more focused trials , aerobic exercise may be an attractive option to manage sleep dysfunction in patients with cancer because of its favorable safety profile and other documented health benefits . Cancer Epidemiol Biomarkers Prev ; 21(6 ) ; 887–94 . © 2012 AACR STUDY OBJECTIVE To assess the short-term efficacy of a video-based cognitive behavioral therapy for insomnia ( CBT-I ) as compared to a professionally administered CBT-I and to a no-treatment group . DESIGN R and omized controlled trial . SETTING Radio-oncology department of a public hospital affiliated with Université Laval ( CHU de Québec ) . PARTICIPANTS Two hundred forty-two women with breast cancer who had received radiation therapy in the past 18 mo and who had insomnia symptoms or were using hypnotic medications were r and omized to : ( 1 ) professionally administered CBT-I ( PCBT-I ; n = 81 ) ; ( 2 ) video-based CBT-I ( VCBT-I ; n = 80 ) ; and ( 3 ) no treatment ( CTL ; n = 81 ) . INTERVENTIONS PCBT-I composed of six weekly , individual sessions of approximately 50 min ; VCBT-I composed of a 60-min animated video + six booklets . MEASUREMENT AND RESULTS Insomnia Severity Index ( ISI ) total score and sleep parameters derived from a daily sleep diary and actigraphy , collected at pretreatment and posttreatment . PCBT-I and VCBT-I were associated with significantly greater sleep improvements , assessed subjectively , as compared to CTL . However , relative to VCBT-I , PCBT-I was associated with significantly greater improvements of insomnia severity , early morning awakenings , depression , fatigue , and dysfunctional beliefs about sleep . The remission rates of insomnia ( ISI < 8) were significantly greater in PCBT-I as compared to VCBT-I ( 71.3 % versus 44.3 % , P < 0.005 ) . CONCLUSIONS A self-administered cognitive behavioral therapy for insomnia ( CBT-I ) using a video format appears to be a valuable treatment option , but face-to-face sessions remain the optimal format for administering CBT-I efficaciously in patients with breast cancer . Self-help interventions for insomnia may constitute an appropriate entry level as part of a stepped care model . TRIAL REGISTRATION Clinical Trials.gov Identifier : NCT00674830 . CITATION Savard J , Ivers H , Savard MH , Morin CM . Is a video-based cognitive behavioral therapy for insomnia as efficacious as a professionally administered treatment in breast cancer ? Results of a r and omized controlled trial Objective : Hot flashes are a major quality -of-life issue for breast cancer survivors , interrupting sleep , reducing quality of life , and diminishing treatment adherence to adjuvant endocrine therapies . Serotonin-norepinephrine reuptake inhibitors ( SNRIs ) and selective serotonin reuptake inhibitors ( SSRIs ) are used widely but are only partially effective for hot flashes . Alternative strategies are needed . We hypothesized that augmentation of SSRI/SNRI therapy with hypnotic agents would optimize hot flash therapy by improving sleep and quality of life . Methods : Women with breast cancer or at high risk for developing the disease who had hot flashes in association with nocturnal awakenings were r and omized to double-blinded treatment with zolpidem 10 mg or placebo for 5 weeks .  SSRI/SNRI nonusers ( 81 % ) started venlafaxine XR 75 mg/day concurrently , whereas SSRI/SNRI users continued that therapy . We compared the proportion of responders , defined as study completers with improved subjective sleep quality ( Pittsburgh Sleep Quality Index ) and /or objective ly assessed wake time after sleep onset on actigraphy , between groups . Results : Of 53 women ( aged 51 ± 8 y ) r and omized to zolpidem augmentation ( n = 25 ) or placebo augmentation ( n = 28 ) , 38 completed the protocol ( 57 % on placebo , 88 % on zolpidem ) . More women augmented with zolpidem than placebo were responders on the sleep outcome ( 40 % vs 14 % ; P = 0.035 ) . Quality of life improved more with zolpidem than with placebo ( P = 0.01 ) . Treatment effects on hot flashes and mood did not differ between groups . Conclusions : Augmentation of SSRI/SNRI with zolpidem improves sleep and quality of life in breast cancer survivors with hot flashes and associated sleep disturbance . Adding a hypnotic agent to an SSRI/SNRI helps women to sleep through nighttime hot flashes . Treatments targeting sleep may be an important supplemental strategy to optimize well-being OBJECTIVE The purpose of this study was to investigate the effects of mindfulness-based stress reduction for  breast cancer survivors ( MBSR(BC ) ) on multiple measures of objective and subjective sleep parameters among breast cancer survivors ( BCS ) . METHODS Data were collected using a two-armed r and omized controlled design among BCS enrolled in either a 6-week MBSR(BC ) program or a usual care ( UC ) group with a 12-week follow-up . The present analysis is a subset of the larger parent trial ( Clinical Trials.gov Identifier : NCT01177124 ) . Seventy-nine BCS participants ( mean age 57 years ) , stages 0-III , were r and omly assigned to either the formal ( in-class ) 6-week MBSR(BC ) program or UC .  Subjective sleep parameters ( SSP ) ( i.e. , sleep diaries and the Pittsburgh Sleep Quality Index ( PSQI ) ) and objective sleep parameters ( OSP ) ( i.e. , actigraphy ) were measured at baseline , 6 weeks , and 12 weeks after completing the MBSR(BC ) or UC program . RESULTS Results showed indications of a positive effect of MBSR(BC ) on OSP at 12 weeks on sleep efficiency ( 78.2 % MBSR(BC ) group versus 74.6 % UC group , p = 0.04 ) , percent of sleep time ( 81.0 % MBSR(BC ) group versus 77.4 % UC group , p = 0.02 ) , and less number waking bouts ( 93.5 in MBSR(BC ) group versus 118.6 in the UC group , p < 0.01 ) . Small nonsignificant improvements were found in SSP in the MBSR(BC ) group from baseline to 6 weeks ( PSQI total score , p = 0.09 ) . No significant relationship was observed between minutes of MBSR(BC ) practice and SSP or OSP . CONCLUSIONS These data suggest that MBSR(BC ) may be an efficacious treatment to improve objective and subjective sleep parameters in BCS PURPOSE / OBJECTIVES To determine the efficacy of a cognitive-behavioral intervention for treating insomnia in breast cancer survivors . DESIGN R and omized controlled trial . SETTING University and medical center setting s. SAMPLE 72 women at least three months after primary treatment for breast cancer with sleep-onset or sleep maintenance insomnia at least three nights per week for at least three months as determined through daily sleep diaries . METHODS R and om assignment to a multicomponent intervention ( stimulus control instructions , sleep restriction , and sleep education and hygiene ) or a single-component control group ( sleep education and hygiene ) . MAIN RESEARCH VARIABLES Sleep-onset latency , wake after sleep onset , total sleep time , time in bed , sleep efficiency , and sleep quality . FINDINGS After the intervention , both groups improved on sleep-onset latency , wake after sleep onset , total sleep time , time in bed , sleep efficiency , and sleep quality based on daily sleep diaries . A between-group difference existed for time in bed . Wrist actigraph data showed significant pre- to postintervention changes for sleep-onset latency , wake after sleep onset , total sleep time , and time in bed . When compared to the control group , the multicomponent intervention group rated overall sleep as more improved . CONCLUSIONS A nonpharmacologic intervention is effective in the treatment of insomnia in breast cancer survivors . IMPLICATION S FOR NURSING Breast cancer survivors can benefit from a cognitive-behavioral intervention for chronic insomnia . Sleep education and hygiene , a less complex treatment than a multicomponent intervention , also is effective in treating insomnia OBJECTIVES Insomnia patients complain that mental events keep them awake . This study investigates how cognitive behavioural therapy ( CBT ) affects such events and considers how attributional , cognitive and psychopathological symptoms may mediate sleep improvement . METHOD A pragmatic , parallel-group r and omized controlled trial of 164 adults ( 120 F : ( mean 49 years ( 18 - 78 years ) ) meeting Diagnostic and Statistical Manual of Mental Disorders , 5th Edition ( DSM-5 ) criteria for insomnia disorder , assigned to CBT ( n=55 ; 40 F ) , imagery relief therapy ( IRT placebo ; n=55 ; 42 F ) , or treatment as usual ( TAU ; n=54 ; 38 F ) , was conducted . CBT/IRT comprised six online sessions delivered by an animated therapist , with automated web/e-mail support . CBT users had access to a moderated community . TAU comprised ' usual care ' . Participants completed the Sleep Disturbance Question naire ( SDQ ) , Glasgow Content of Thoughts Inventory ( GCTI ) , Depression Anxiety and Stress Scales ( DASS ) and Sleep Condition Indicator ( SCI ) at baseline , post treatment and 8-week follow-up . RESULTS The sample was characterised by mental arousal , notably ' trying too hard ' to sleep ( SDQ ) , and by ' sleep and sleeplessness ' and ' rehearsal and planning ' thoughts ( GCTI ) . Treatment effects were observed for all SDQ domains ( e.g. , CBT vs. IRT : d=0.76 for ' trying too hard ' ) . CBT was also superior to IRT on the GCTI ( e.g. , ' rehearsal and planning ' , d=0.62 ; ' sleep and sleeplessness ' , d=0.74 ) . CBT vs. TAU comparisons yielded larger effects , whereas placebo effects ( IRT vs. TAU ) were small to moderate . Hierarchical regression demonstrated partial mediation of SCI improvement by attributional and cognitive factors ( R2 = 21 - 27 % ) following CBT . Improvement in sleep efficiency appears to be independent of such factors . CONCLUSION Online CBT modifies sleep-related attributions , night-time thought content and psychopathology . This process partly mediates improvement in DSM-5-defined insomnia PURPOSE / OBJECTIVES To compare the effectiveness of a prescribed home-based walking exercise intervention with usual care in older women receiving hormonal treatment for breast cancer , and to examine relationships among levels of the cortisol , serotonin , interleukin-6 , and bilirubin biomarkers and fatigue , sleep disturbances , and depressive symptoms . DESIGN Longitudinal r and omized clinical trial . SETTING A National Cancer Institute- design ated cancer center in the southeastern United States . SAMPLE 20 women ( aged 55 years or older ) with breast cancer receiving hormonal treatment . METHODS Participants were r and omized to a walking exercise intervention or usual care . Laboratory sample s and the Pittsburgh Sleep Quality Index ( PSQI ) , the Piper Revised Fatigue Scale , and the Center for Epidemiological Studies -Depression Scale were collected at the initial clinic visit and at 12 weeks from the groups . Question naires also were collected at weeks 2 and 14 . MAIN RESEARCH VARIABLES Fatigue , sleep disturbances , depressive symptoms , biomarkers , and exercise . FINDINGS Effect of the exercise intervention on sleep scores was highly significant between groups . Exercise group scores on the PSQI decreased significantly over time ( indicating improved sleep quality ) , although scores did not change significantly within the control group . Sleep actigraphy also showed significantly shorter actual wake time and less movement in the exercise group . Serotonin levels also were significantly affected by the intervention . CONCLUSIONS Data suggest that a walking exercise intervention improves sleep in older women receiving hormonal treatment for their breast cancer . Serotonin levels may be a useful biomarker when assessing sleep disturbances in this group . IMPLICATION S FOR NURSING Clinicians need to be aware that older women receiving hormonal treatment for their breast cancer may experience fatigue , sleep disturbances , and depressive symptoms . Homebased walking activity may reduce symptom severity in this group PURPOSE / OBJECTIVES To compare usual care with a home-based individualized exercise program ( HBIEP ) in patients receiving intensive treatment for multiple myeloma ( MM ) and epoetin alfa therapy .  DESIGN R and omized trial with repeated measures of two groups ( one experimental and one control ) and an approximate 15-week experimental period . SETTING Outpatient setting of the Myeloma Institute for Research and Therapy at the Rockfellow Cancer Center at the University of Arkansas for Medical Sciences . SAMPLE 187 patients with newly diagnosed MM enrolled in a separate study evaluating effectiveness of the Total Therapy regimen , with or without thalidomide . METHODS Measurements included the Profile of Mood States fatigue scale , Functional Assessment of Cancer Therapy-Fatigue , ActiGraph ® recordings , 6-Minute Walk Test , and hemoglobin levels at baseline and before and after stem cell collection . Descriptive statistics were used to compare demographics and treatment effects , and repeated measures analysis of variance was used to determine effects of HBIEP . MAIN RESEARCH VARIABLES Fatigue , nighttime sleep , performance ( aerobic capacity ) as dependent or outcome measures , and HBIEP combining strength building and aerobic exercise as the independent variable . FINDINGS Both groups were equivalent for age , gender , race , receipt of thalidomide , hemoglobin levels , and type of treatment regimen for MM . No statistically significant differences existed among the experimental and control groups for fatigue , sleep , or performance ( aerobic capacity ) . Statistically significant differences ( p < 0.05 ) were found in each of the study outcomes for all patients as treatment progressed and patients experienced more fatigue and poorer nighttime sleep and performance ( aerobic capacity ) . CONCLUSIONS The effect of exercise seemed to be minimal on decreasing fatigue , improving sleep , and improving performance ( aerobic capacity ) . IMPLICATION S FOR NURSING Exercise is safe and has physiologic benefits for patients undergoing MM treatment ; exercise combined with epoetin alfa helped alleviate anemia Background : The natural hormone melatonin has sleep inducing properties . Insomnia in cancer patients is common . So far , melatonin has been seldom tried for the improvement of sleep in patients with malignancies . Keeping this in mind , we planned and conducted a double-blind study to test the efficacy of melatonin in promoting sleep in patients with malignancies suffering from insomnia . Objective : To assess the hypnotic efficacy of oral melatonin in cancer patients with insomnia . Material s and Methods : After Ethical Committee approval , 50 patients ( age range 20 - 65 years ) from our pain clinic " NIVARANE " who met the Diagnostic and Statistical Manual of Mental Disorders 4 th edition criteria for primary insomnia were r and omized to receive melatonin 3 mg or placebo at 7 pm orally every day for 14 days from our pharmacist . After 1 , 7 , 14 days , the patients were review ed with the Athens insomnia scale oral question naire to document the subjective sleep quality . The patients and we , the investigators were blinded to the study drug . Results : There were 2 drop outs ( one from each group ) as they failed to complete visit on day 14 . Significant differences in favor of melatonin treatment were found in clinical ly relevant improvements in insomnia ( 46.53 % ; P = 0.00001 vs. 11.30 % ; P = 0.1026 ) There was improvement in sleep from 1 to 7 days ( 19.91 % ; P = 0.00001 vs. 0.98 % ; P = 0.2563 ) . More significant improvements were seen between 7 and 14 days ( 33.24 % ; P = 0.00001 vs. 10.42 % ; P = 0.1469 ) . Conclusion : We conclude that daily intake of oral melatonin 2 h before bedtime improves sleep induction and quality in cancer patients with insomnia OBJECTIVES This secondary analysis of data from a r and omised controlled trial explores associations between common symptom clusters and evaluates pre-treatment to post-treatment changes in clinical levels of these symptoms following cognitive behaviour therapy for insomnia ( CBT-I ) . METHODS Baseline data from 113 participants with insomnia were explored to establish rates of and associations between clinical levels of fatigue , anxiety and depression across the sample . Effects of CBT-I on this symptom cluster were also explored by examining changes in pre-treatment to post-treatment levels of fatigue , anxiety and depression . RESULTS At baseline , the most common symptom presentation was insomnia + fatigue , and 30 % of the sample reported at least three co-morbid symptoms . Post-CBT , the number of those experiencing clinical insomnia and clinical fatigue decreased . There were no changes in anxiety rates from baseline to post-treatment in the CBT group and modest reductions in rates of those with clinical depression . Seven individuals ( 9.6 % ) from the CBT group were completely symptom free at post-treatment compared with 0 % from the treatment as usual condition . Chi-square analysis revealed a significant relationship between group allocation and changes in symptoms of insomnia and fatigue . No such relationship was found between group allocation and mood variables . CONCLUSIONS These findings confirm the high rate of symptom co-morbidities among cancer patients and highlight strong associations between sleep and fatigue .  CBT-I appears to offer generalised benefit to the symptom cluster as a whole and , specifically , is effective in reducing fatigue , which exceeded clinical cut-offs prior to implementation of the intervention . This has implication s for the diagnosis/management of common symptoms in cancer patients Fatigue and insomnia are problems for patients with cancer . Research findings show that aerobic exercise decreases cancer-related fatigue . Because patients with cancer who have skeletal muscle wasting may not obtain maximum benefit from aerobic exercise training , exercise programs may need to include resistance training . Thus far , testing exercise as an intervention for fatigue has focused on patients with breast cancer and excluded patients with bone metastasis . There is a need to test the feasibility and effectiveness of exercise for patients with other types of cancer and with bone involvement . The effect of aerobic and strength resistance training on the sleep of patients with cancer has not been tested . A pilot/feasibility study with a r and omized controlled design was conducted to investigate homebased exercise therapy for 24 patients receiving high-dose chemotherapy and autologous peripheral blood stem cell transplantation as treatment for multiple myeloma . None of the patients injured themselves . Because of the small sample size in the feasibility study , the effect of exercise on lean body weight was the only end point that obtained statistical significance . However , the results suggest that an individualized exercise program for patients receiving aggressive treatment for multiple myeloma is feasible and may be effective for decreasing fatigue and mood disturbance , and for improving sleep Background Sleep disruption and fatigue are ubiquitous among cancer patients and are sources of stress that may compromise treatment outcomes . Previously , we showed that a cognitive behavioral stress management ( CBSM ) intervention reduced anxiety and other stress-related processes in women undergoing primary treatment for breast cancer . Purpose This study examined secondary outcomes from a CBSM intervention trial for women with early-stage breast cancer to test if CBSM would improve sleep quality and fatigue among these patients at a single site in southern Florida .  CBSM-related effects have already been demonstrated for indicators of psychosocial adaptation ( e.g. , general and cancer-related anxiety ) . Methods Patients were r and omized to CBSM ( n= 120 ) or a 1-day psychoeducation control group ( n= 120 ) . The  Pittsburgh Sleep Quality Index ( PSQI ) and Fatigue Symptom Inventory  were completed prior to r and omization and 6 and 12 months after the baseline assignment . Results In latent growth analyses , women in CBSM reported greater improvements in PSQI sleep quality scores than controls , although there were no significant differences between conditions on PSQI total scores . Women in CBSM also reported greater reductions in fatigue-related daytime interference than controls , though there were no significant differences in changes in fatigue intensity . Changes in sleep quality were associated with changes in fatigue . Conclusions Future work may consider integrating sleep and fatigue content into stress management interventions for women with early-stage breast cancer Background : Cancer treatments can lead to detriments in patients ’ health and declines in quality of life ( QOL ) . Cancer rehabilitation programs may improve functional status , symptom control , and QOL . Objective : The objective of this study was to determine if an outpatient , physical therapy – supervised Cancer Rehabilitation Strengthening and Conditioning ( CRSC ) program improved patients ’ conditioning level , functional status , QOL , and symptoms . Methods : This was a prospect i ve study of oncology patients participating in CRSC program .  Measurements included conditioning level ( 6-minute walk test [ SMWT ] , metabolic equivalent level , grip strength ) , functional status ( Physical Component Summary of Short Form 36 ) , QOL ( Mental Component Summary of Short Form 36 ) , and symptoms ( M. D. And erson Symptom Inventory ) . Paired t tests were conducted to determine significant changes between pre- and post-CRSC program measures , and regression methods identified predictors of change from baseline . Results : One hundred fifteen patients with cancer were enrolled in the study ; 75 patients completed pre- and post-CRSC program measures . Significant improvements were noted in SMWT by 186.4 ft , SMWT speed by 0.35 mph , treadmill time ( 3.5 minutes longer ) , metabolic equivalent level ( by 0.87 units ) , QOL , symptom severity , symptom interference with daily life , fatigue , shortness of breath , and sadness . Conclusions : In a pretest-posttest design , significant improvements were noted in conditioning level , functional status , QOL , and symptoms . Greater improvements were noted in participants who were most deconditioned at baseline . Implication s for Practice : Further research should be conducted to provide additional support for CRSC programs . Cancer rehabilitation strengthening and condition programs may benefit patients across the continuum of care , including deconditioned patients PURPOSE Chronic insomnia is highly prevalent in cancer patients .  Cognitive-behavioral therapy ( CBT ) is considered the treatment of choice for chronic primary insomnia . However , no r and omized controlled study has been conducted on its efficacy for  insomnia secondary to cancer . Using a r and omized controlled design , this study conducted among breast cancer survivors evaluated the effect of CBT on sleep , assessed both subjectively and objective ly , and on hypnotic medication use , psychological distress , and quality of life . PATIENTS AND METHODS Fifty-seven women with insomnia caused or aggravated by breast cancer were r and omly assigned to CBT ( n = 27 ) or a waiting-list control condition ( n = 30 ) . The treatment consisted of eight weekly sessions administered in a group and combined the use of stimulus control , sleep restriction , cognitive therapy , sleep hygiene , and fatigue management . Follow-up evaluations were carried out 3 , 6 , and 12 months after the treatment . RESULTS Participants who received the insomnia treatment had significantly better subjective sleep indices ( daily sleep diary , Insomnia Severity Index ) , a lower frequency of medicated nights , lower levels of depression and anxiety , and greater global quality of life at post-treatment compared with participants of the control group after their waiting period . Results were more equivocal on polysomnographic indices . Therapeutic effects were well maintained up to 12 months after the intervention and generally were clinical ly significant . CONCLUSION This study supports the efficacy of CBT for insomnia secondary to breast cancer This study describes , and examines the initial efficacy of , a sleep therapy programme developed for cancer patients with insomnia . The six-session group programme included stimulus control therapy , relaxation training , and other strategies aim ed at consolidating sleep and reducing cognitive-emotional arousal . The 12 final participants were patients of a regional cancer centre ; mean age was 54.7 years ( S.D. 10.4 ) ; median time from cancer diagnosis was 33.6 months ; all had high performance status . Participants kept sleep diaries and rated their sleep quality , mood and functioning at baseline , week 4 and week 8 . Significant improvement over baseline was observed at weeks 4 and 8 in the number of awakenings , time awake after sleep onset , sleep efficiency , sleep quality ratings , and scores on European Organization for Research and Treatment of Cancer ( EORTC ) QLQ-C30 role functioning and insomnia . Total sleep time and fatigue were significantly improved at week 8 . The sleep therapy programme was associated with improved sleep , reduced fatigue and enhanced ability to perform activities in relatively well individuals attending a cancer centre . This is preliminary evidence of the efficacy of the programme . Further research is required to examine the programme 's effectiveness and suitability for a wider range of people with cancer . Options for providing cancer patients with access to nonpharmacologic treatments for insomnia are discussed To examine the effects of different doses and types of exercise on sleep quality in breast cancer patients receiving chemotherapy . A multicenter trial in Canada r and omized 301 breast cancer patients between 2008 and 2011 to thrice weekly , supervised exercise during chemotherapy  consisting of either a st and ard dose of 25–30 min of aerobic exercise ( STAN ; n = 96 ) , a higher dose of 50–60 min of aerobic exercise ( HIGH ; n = 101 ) , or a combined dose of 50–60 min of aerobic and resistance exercise ( COMB ; n = 104 ) . The secondary sleep outcomes in the trial were assessed by the Pittsburgh Sleep Quality Index ( PSQI ) at baseline , twice during chemotherapy , and postchemotherapy . We analyzed the global PSQI and the component scores . Repeated measures analyses of variance indicated that the HIGH group was statistically superior to the STAN group for global sleep quality ( mean group difference = −0.90 ; 95 % CI −0.05 to −1.76 ; p = 0.039 ) as well as subjective sleep quality ( p = 0.028 ) and sleep latency ( p = 0.049 ) . The COMB group was borderline statistically superior to the STAN group for global sleep quality ( mean group difference = −0.76 ; 95 % CI + 0.11 to −1.62 ; p = 0.085 ) as well as sleep duration ( p = 0.051 ) ; and statistically superior for sleep efficiency ( p = 0.040 ) , and percentage of poor sleepers ( p = 0.045 ) . Compared to a st and ard volume of aerobic exercise , higher volumes of both aerobic and combined exercise improved some aspects of sleep quality during breast cancer chemotherapy . Exercise may be an attractive option to manage sleep dysfunction  in cancer patients during chemotherapy Background : Insomnia is a prevalent health complaint that is often difficult to evaluate reliably . There is an important need for brief and valid assessment tools to assist practitioners in the clinical evaluation of insomnia complaints . Objective : This paper reports on the clinical validation of the  Insomnia Severity Index ( ISI )  as a brief screening measure of insomnia and as an outcome measure in treatment research . The psychometric properties ( internal consistency , concurrent validity , factor structure ) of the ISI were evaluated in two sample s of insomnia patients . Methods : The first study examined the internal consistency and concurrent validity of the ISI  in 145 patients evaluated for insomnia at a sleep disorders clinic . Data from the ISI were compared to those of a sleep diary measure . In the second study , the concurrent validity of the  ISI  was evaluated in a sample of 78 older patients who participated in a r and omized-controlled trial of behavioral and pharmacological therapies for insomnia . Change scores on the  ISI  over time were compared with those obtained from sleep diaries and polysomnography .  Comparisons were also made between ISI scores obtained from patients , significant others , and clinicians . Results : The results of Study 1 showed that the  ISI  has adequate internal consistency and is a reliable self-report measure to evaluate perceived sleep difficulties . The results from Study 2 also indicated that the ISI is a valid and sensitive measure to detect changes in perceived sleep difficulties with treatment . In addition , there is a close convergence between scores obtained from the ISI patient 's version and those from the clinician 's and significant other 's versions . Conclusions : The present findings indicate that the ISI is a reliable and valid instrument to quantify perceived insomnia severity . The ISI is likely to be a clinical ly useful tool as a screening device or as an outcome measure in insomnia treatment research Purpose Fatigue is a prevalent , distressing side effect of cancer and cancer treatment which commonly coexists with insomnia . Cognitive behavioral therapy for insomnia ( CBT-I ) has been shown to improve insomnia  in cancer patients , but less is known about its ability to impact fatigue . This work is the analysis for a secondary aim of a four-arm r and omized controlled trial ( RCT ) study assessing the combined and comparative effect of CBT-I and a wakefulness-promoting agent , armodafinil ( A ) , to improve sleep and daytime functioning in cancer survivors . Herein , we examine the effect of CBT-I , with and without A , on fatigue in cancer survivors . Patients and methods This study was a four-arm factorial study with CBTI-I ( yes/no ) versus A ( yes/no ) . It consisted of 96 cancer survivors ( average age 56 years ; 88 % female ; 68 % breast cancer ) .  Fatigue was assessed by the brief fatigue inventory ( BFI ) and the FACIT-Fatigue scale . The analysis assessed the additive effects of CBT-I and A and possible non-additive effects where the effect of CBT-I changes depending on the presence or absence of A. Results Analyses adjusting for baseline differences showed that CBT-I  improved fatigue as measured by two separate scales ( BFI : P = 0.002 , Std . error = 0.32 , effect size ( ES ) = 0.46 ; FACIT-Fatigue : P < 0.001 , Std . error = 1.74 , ES = 0.64 ) . Armodafinil alone did not show a statistically significant effect on fatigue levels ( all Ps > 0.40 ) nor did the drug influence the efficacy of CBT-I. Structural equation analysis revealed that reductions in insomnia severity were directly responsible for improving cancer-related fatigue . Conclusions CBT-I with and without armodafinil result ed in a clinical ly and statistically significant reduction of subjective daytime fatigue in cancer survivors with chronic insomnia . Armodafinil did not improve cancer-related fatigue ( CRF ) and did not change the efficacy of CBT-I. Patients reporting CRF should be screened and , if indicated , treated for insomnia as part of a comprehensive fatigue management program CONTEXT Exercise benefits patients with cancer , but studies of home-based approaches , particularly among those with Stage IV disease , remain small and exploratory . OBJECTIVES To conduct an adequately powered trial of a home-based exercise intervention that can be facilely integrated into established delivery and reimbursement structures . METHODS Sixty-six adults with Stage IV lung or colorectal cancer were r and omized , in an eight-week trial , to usual care or incremental walking and home-based strength training . The exercising participants were instructed during a single physiotherapy visit and subsequently exercised four days or more per week ; training and step-count goals were advanced during bimonthly telephone calls . The primary outcome measure was mobility assessed with the Ambulatory Post Acute Care Basic Mobility Short Form . Secondary outcomes included ratings of pain and sleep quality as well as the ability to perform daily activities ( Ambulatory Post Acute Care Daily Activities Short Form ) , quality of life ( Functional Assessment of Cancer Therapy-General ) , and fatigue ( Functional Assessment of Cancer Therapy-Fatigue ) . RESULTS Three participants dropped out and seven died ( five in the intervention and two in the control group , P=0.28 ) . At Week 8 , the intervention group reported improved mobility ( P=0.01 ) , fatigue ( P=0.02 ) , and sleep quality ( P=0.05 ) compared with the usual care group , but did not differ on the other measures . CONCLUSION A home-based exercise program seems capable of improving the mobility , fatigue , and sleep quality of patients with Stage IV lung and colorectal cancer OBJECTIVE Insomnia is a common complaint among cancer survivors . Fortunately , cognitive-behavioral therapy for insomnia ( CBT-I ) has been shown to be an effective treatment in this population . However , it is rarely implemented given its limited availability . To address this barrier , we examined the ability of an easily accessible online CBT-I program to improve insomnia symptoms in cancer survivors . METHODS Twenty-eight cancer survivors with insomnia were r and omly assigned to either an Internet insomnia intervention ( n = 14 ) or to a waitlist control group ( n = 14 ) . The online program , Sleep Healthy Using The Internet , delivers the primary components of CBT-I ( sleep restriction , stimulus control , cognitive restructuring , sleep hygiene , and relapse prevention ) . Pre- and post- assessment data were collected via online question naires and daily sleep diaries . RESULTS Participants in the Internet group showed significant improvements at post- assessment compared with those in the control group in overall insomnia severity ( F(1,26 ) = 22.8 ; p<0.001 ) , sleep efficiency ( F(1,24 ) = 11.45 ; P = 0.002 ) , sleep onset latency ( F(1,24 ) = 5.18 ; P = 0.03 ) , soundness of sleep ( F(1,24 ) = 9.34 ; P = 0.005 ) , restored feeling upon awakening ( F(1,24 ) = 11.95 ; P = 0.002 ) , and general fatigue ( F(1,26 ) = 13.88 ; P = 0.001 ) . Although other group × time interactions were not significant , overall adjusted effect sizes for all sleep variables as well as for fatigue , depression , anxiety , and quality of life ranged from small to large . CONCLUSIONS CBT-I delivered through an interactive , individually tailored Internet intervention may be a viable treatment option for cancer survivors experiencing insomnia The purpose is to examine the effects of melatonin supplementation on sleep , mood , and hot flashes in postmenopausal breast cancer survivors . In a r and omized , double-blind , placebo-controlled study , 95 postmenopausal women with a prior history of stage 0–III breast cancer , who had completed active cancer treatment ( including hormonal therapy ) were r and omly assigned 1:1 to either 3 mg oral melatonin ( n = 48 ) or placebo daily ( n = 47 ) for 4 months . Sleep , mood , and hot flashes were assessed at baseline and 4 months via self-administered question naire using the Pittsburgh Sleep Quality Index ( PSQI ) , Center for Epidemiologic Studies —Depression ( CES-D ) , and the North Central Cancer Treatment Group ( NCCTG ) hot flash diary , respectively . Eighty-six women ( 91 % ) completed the study and provided pre- and post- question naires . At baseline , 52 % of participants reported poor sleep in the month prior to enrollment . Compared to subjects on placebo , subjects r and omized to melatonin experienced significantly greater improvements in subjective sleep quality as measured by the PSQI , including domains on sleep quality , daytime dysfunction and total score . For example , the mean change in PSQI score was −0.1 in the placebo group compared to −1.9 in the melatonin group ( p < 0.001 ) . There were no significant differences in measures of depression or hot flashes . Sleep disturbances are common among breast cancer survivors , even after completion of active cancer treatment . This is the first r and omized placebo-controlled study among breast cancer survivors to demonstrate that melatonin was associated with an improvement in subjective sleep quality , without any significant adverse effects PURPOSE / OBJECTIVES To evaluate the feasibility of an intervention design ed to promote sleep and modify fatigue during four cycles of adjuvant breast cancer chemotherapy . DESIGN Prospect i ve , repeated measures , quasi-experimental feasibility study . SETTING Midwestern urban oncology clinics . SAMPLE 25 women between the ages of 40 - 65 ( mean = 54.3 ) with stage I-II breast cancer receiving doxorubicin-based chemotherapy . METHODS Each woman developed , reinforced , and revised an individualized sleep promotion plan ( ISPP ) with four components : sleep hygiene , relaxation therapy , stimulus control , and sleep restriction techniques . A daily diary , the Pittsburgh Sleep Quality Index , a wrist actigraph , and the Piper Fatigue Scale were used to collect data two days before and seven days after each treatment . MAIN RESEARCH VARIABLES Adherence , sleep and wake outcomes , and fatigue . FINDINGS Adherence rates with the components of the ISPP varied during treatments one through four : sleep hygiene ( 68%-78 % ) , relaxation therapy ( 57%-67 % ) , stimulus control ( 46%-67 % ) , and sleep restriction ( 76%-80 % ) . Mean sleep and wake outcomes at baseline , peak , and rebound times were that ( a ) sleep latency remained brief ( less than 30 minutes per night ) , ( b ) time awake after sleep onset exceeded the desired less than 30 minutes per night , ( c ) sleep efficiency scores remained stable at 85%-90 % , ( d ) total rest time remained stable at 8 - 10 hours per night , ( e ) subjective ratings of feelings on arising were stable , and ( f ) nighttime awakenings were 8 - 10 per night . Fatigue outcomes were that fatigue was stable two days after each treatment and mean daily fatigue intensity was lower at treatment three than at treatment one but rebounded at treatment four . CONCLUSIONS The intervention was feasible , adherence rates improved over time , and most sleep and wake patterns were consistent with normal values . Revisions will focus on decreasing nighttime awakenings . IMPLICATION S FOR NURSING Adopting behaviors to promote sleep may assist in maintaining sleep and managing fatigue during chemotherapy Cancer patients often report impaired sleep quality . Impaired sleep quality may be due to increased levels of sleep-mediating cytokines result ing from cancer treatment . Exercise may have a positive influence on sleep-mediating cytokines , such as interleukin-6 ( IL-6 ) , tumor necrosis factor-alpha ( TNF-α ) , and soluble tumor necrosis factor-alpha receptor ( sTNF-R ) , which may improve sleep quality . This two-arm pilot study compared the influence of a home-based exercise intervention with st and ard care/control on sleep quality and mediators of sleep . Breast and prostate cancer patients ( n = 38 ) beginning radiation therapy were r and omized to a 4-week exercise program or no exercise arm . Global sleep quality , subjective sleep quality , sleep latency , sleep duration , sleep efficiency , sleep disturbances , use of sleep medication , and daytime dysfunction were assessed with the Pittsburgh Sleep Quality Index . IL-6 , TNF-α , and sTNF-R were measured before and after intervention . There was a greater improvement in sleep quality in the exercise  group from pre- to postintervention , although the difference was not significant . Additionally , there were associations between IL-6 and sleep efficiency and duration , suggesting that regulation of sleep-mediating cytokines by exercise may mediate improvements in sleep- quality components Background : Sleep disturbances and poor rest-activity rhythms , which can reduce the quality of life , are highly prevalent among patients with lung cancer . Methods : This trial investigated the effects of a 12-week exercise intervention including home-based walking exercise training and weekly exercise counseling on 111 lung cancer patients . Participants were r and omly allocated to receive the intervention or usual-care . Outcomes included objective sleep ( total sleep time , TST ; sleep efficiency , SE ; sleep onset latency , SOL ; and wake after sleep onset , WASO ) , subjective sleep ( Pittsburgh Sleep Quality Index , PSQI ) , and rest-activity rhythms ( r24 and I < O ) . Outcomes were assessed at baseline and 3 and 6 months after intervention . Results : The PSQI ( Wald χ2=15.16 , P=0.001 ) and TST ( Wald χ2=7.59 , P=0.023 ) of the patients in the exercise group significantly improved 3 and 6 months after intervention . The moderating effect of I < O on TST was significant ( β of group × I < O=3.70 , P=0.032 ) . Conclusions : The walking program is an effective intervention for improving the subjective and objective sleep quality of lung cancer patients and can be considered an optional component of lung cancer rehabilitation PURPOSE / OBJECTIVES To examine the effect of cognitive-behavioral therapy for insomnia ( CBTI ) on sleep improvement , daytime symptoms , and quality of life ( QOL ) in breast cancer survivors ( BCSs ) after cancer treatment . DESIGN A prospect i ve , longitudinal , r and omized , controlled trial . SETTING Oncology clinics , breast cancer support groups , and communities in Colorado . SAMPLE 56 middle-aged BCSs with chronic insomnia . METHODS Women were r and omly assigned to CBTI or behavioral placebo treatment ( BPT ) and completed measures of sleep , QOL , functioning , fatigue , and mood at baseline , postintervention , and at three- and six-month follow-ups . MAIN RESEARCH VARIABLES Sleep outcomes ( e.g. , sleep efficiency , sleep latency , total sleep time , wake after sleep onset , number of nightly awakenings ) ; secondary variables included sleep medication use , insomnia severity , QOL , physical function , cognitive function , fatigue , depression , anxiety , and sleep attitudes or knowledge . FINDINGS Sleep efficiency and latency improved more in the CBTI group than the BPT group ; this difference was maintained during follow-up . Women in the CBTI group had less subjective insomnia , greater improvements in physical and cognitive functioning , positive sleep attitudes , and increased sleep hygiene knowledge . No group differences in improvement were noted relative to QOL , fatigue , or mood . CONCLUSIONS Nurse-delivered CBTI appears to be beneficial for BCSs ' sleep latency/efficiency , insomnia severity , functioning , sleep knowledge , and attitudes more than active placebo , with sustained benefit over time . IMPLICATION S FOR NURSING Oncology nurses are in a unique position to identify insomnia in cancer survivors . When sleep disturbances become chronic , nurses need to make recommendations and referrals Exercise use among patients with cancer has been shown to have many benefits and few notable risks . The purpose of this study was to evaluate the impact of a home-based walking intervention during cancer treatment on sleep quality , emotional distress , and fatigue . Methods . A total of 138 patients with prostate ( 55.6 % ) , breast ( 32.5 % ) , and other solid tumors ( 11.9 % ) were r and omized to a  home-based walking intervention or usual care . Exercise dose was assessed using a five-item subscale of the Cooper Aerobics Center Longitudinal Study Physical Activity Question naire . Primary outcomes of sleep quality , distress , and fatigue were compared between the two study arms . Results . The exercise group ( n = 68 ) reported more vigor ( p = .03 ) than control group participants ( n = 58 ) . In dose response models , greater participation in aerobic exercise was associated with 11 % less fatigue ( p < .001 ) , 7.5 % more vigor ( p = .001 ) , and 3 % less emotional distress ( p = .03 ) , after controlling for intervention group assignment , age , and baseline exercise and fatigue levels . Conclusion . Patients who exercised during cancer treatment experienced less emotional distress than those who were less active . Increasing exercise was also associated with less fatigue and more vigor .  Home-based walking is a simple , sustainable strategy that may be helpful in improving a number of symptoms encountered by patients undergoing active treatment for cancer OBJECTIVES This study investigated the relationships between a mindfulness-based stress reduction meditation program for early stage breast and prostate cancer patients and quality of life , mood states , stress symptoms , and levels of cortisol , dehydroepi and rosterone-sulfate ( DHEAS ) and melatonin . METHODS Fifty-nine patients with breast cancer and 10 with prostate cancer enrolled in an eight-week Mindfulness-Based Stress Reduction ( MBSR ) program that incorporated relaxation , meditation , gentle yoga , and daily home practice . Demographic and health behavior variables , quality of life , mood , stress , and the hormone measures of salivary cortisol ( assessed three times/day ) , plasma DHEAS , and salivary melatonin were assessed pre- and post-intervention . RESULTS Fifty-eight and 42 patients were assessed pre- and post-intervention , respectively . Significant improvements were seen in overall quality of life , symptoms of stress , and sleep quality , but these improvements were not significantly correlated with the degree of program attendance or minutes of home practice . No significant improvements were seen in mood disturbance . Improvements in quality of life were associated with decreases in afternoon cortisol levels , but not with morning or evening levels . Changes in stress symptoms or mood were not related to changes in hormone levels . Approximately 40 % of the sample demonstrated abnormal cortisol secretion patterns both pre- and post-intervention , but within that group patterns shifted from " inverted-V-shaped " patterns towards more " V-shaped " patterns of secretion . No overall changes in DHEAS or melatonin were found , but nonsignificant shifts in DHEAS patterns were consistent with healthier profiles for both men and women . CONCLUSIONS MBSR program enrollment was associated with enhanced quality of life and decreased stress symptoms in breast and prostate cancer patients , and result ed in possibly beneficial changes in hypothalamic-pituitary-adrenal ( HPA ) axis functioning . These pilot data represent a preliminary investigation of the relationships between MBSR program participation and hormone levels , highlighting the need for better-controlled studies in this area PURPOSE / OBJECTIVES To evaluate outcomes of an intervention design ed to promote sleep and modify fatigue after adjuvant breast cancer chemotherapy . DESIGN Prospect i ve , repeated measures , quasi-experimental , feasibility study . SETTING Midwestern urban oncology clinics . SAMPLE 21 female participants , ages 43 - 66 years ( meanX = 55.3 ) with stage I or II breast cancer status post four cycles of doxorubicin chemotherapy .  Eight had four additional cycles of paclitaxel , 10 also had radiation , and 18 took tamoxifen . METHODS each woman continued to revise her Individualized Sleep Promotion Plan ( ISPP ) , developed during her first cycle of chemotherapy , that included sleep hygiene , relaxation therapy , stimulus control , and sleep restriction components . The  daily diary , Pittsburgh Sleep Quality Index , wrist actigraph , and Piper Fatigue Scale  were used for seven days 30 , 60 , and 90 days after the last chemotherapy treatment and one year after the first chemotherapy treatment . MAIN RESEARCH VARIABLES Adherence and sleep and wake , fatigue , and ISPP components . FINDINGS Adherence to the ISPP components remained high at all times ( 77%-88 % ) except for stimulus control ( 36%-56 % ) . Sleep outcome means and the actigraph revealed that ( a ) sleep latency remained less than 30 minutes per night , ( b ) the time awake after sleep onset exceeded the desired less than 30 minutes per night , ( c ) sleep efficiency scores ranged from 82%-92 % , ( d ) total rest time ranged from seven to eight hours per night , ( e ) feelings on arising ranged from 3.7 - 3.8 ( on a 0 - 5 scale ) , ( f ) nighttime awakenings ranged from 10 - 11 per night , and ( g ) daytime naps ranged from 10 - 15 minutes in length . Fatigue remained low , from 2.9 - 3.5 on a 0 - 10 scale . CONCLUSIONS Adherence rates remained high for most components . Sleep and wake patterns were within normal limits except for the number and duration of night awakenings . Fatigue remained low . IMPLICATION S FOR NURSING Future testing using an experimental design will focus on increasing ISPP adherence and decreasing nighttime awakenings . Adopting behavioral techniques to promote sleep may result in improved sleep and lower fatigue after chemotherapy OBJECTIVES The aim was to explore the cost-utility in providing complementary individual psychosocial support to breast cancer patients compared with st and ard care ( SC ) . METHODS Patients just starting adjuvant therapy ( n = 168 ) at Uppsala University Hospital , Sweden , were consecutively included and r and omized into three groups : psychosocial support from a specially trained nurse ( INS ) , from a psychologist ( IPS ) , or SC .  Psychological effects and healthcare utilization were monitored during a 2-year period . The hospital billing system provided cost estimates . Quality -adjusted life years ( QALYs ) were calculated using health-related quality of life data from the European Organization for Research and Treatment of Cancer Quality of Life Core Question naire ( EORTC QLQ C-30 ) translated into the Euro Quality of Life- 5-Dimensional classification . On the basis of the medical cost offset , a cost-utility analysis was performed . RESULTS Health care utilization was mainly related to the breast cancer diagnosis and treatment . The intervention costs amounted to about € 500 or 3 % of the total costs . Total health care costs , including interventions cost , were lower in the INS ( € 18,670 ) and IPS ( € 20,419 ) groups than in the SC group ( € 25,800 ) . The number of QALYs were also higher in the INS ( 1.52 QALY ) and IPS ( 1.59 QALY ) groups , compared with the SC group ( 1.43 QALY ) . CONCLUSIONS The cost-utility analysis revealed that , during adjuvant treatment for breast cancer , the individual psychosocial support interventions provided here was cost effective because the health care costs were lower and QALYs were higher compared to SC alone STUDY OBJECTIVE Fatigue and sleep disturbances are two of the most common and distressing symptoms of cancer patients . A relationship between the two symptoms was reported in symptom cluster studies ; however , only subjective measurements of sleep were examined and most studies were cross-sectional . In this study of women with breast cancer undergoing chemotherapy  , we explored the longitudinal relationship between fatigue and sleep measured both subjectively and objective ly . DESIGN Prospect i ve study . Data were collected at 7 time points : before ( baseline ) and during the 3 weeks of cycle 1 and cycle 4 chemotherapy . PARTICIPANTS Ninety-seven women with newly diagnosed stage I-III breast cancer who were scheduled to receive at least four 3-week cycles of chemotherapy .  MEASUREMENT AND RESULTS Objective sleep parameters were measured with an Actillume actigraph ( Ambulatory Monitoring Inc. ) . Subjective sleep quality was assessed with the Pittsburgh Sleep Quality Index ( PSQI ) . Fatigue was assessed with the Multidimensional Fatigue Symptom Inventory-Short Form ( MFSI-SF ) . Fatigue became worse during both cycles of chemotherapy ( P-values < 0.01 ) . Subjective sleep quality was poor at baseline and remained unchanged throughout treatment . Objective nighttime and daytime total sleep time increased compared to baseline during the treatment administration week of both cycles ; daytime total wake time decreased during the treatment week of both cycles and during the last 2 week of cycle 4 . Mixed model results revealed that fatigue was positively associated with total PSQI scores and with objective measures of total nap time , and negatively associated with total wake time during the day ( all P-values < 0.01 ) . CONCLUSION Fatigue was significantly associated with subjective reports of poor sleep and objective measures of daytime sleepiness , but not with nocturnal sleep as measured with actigraphy . This relationship between fatigue and sleep warrants further studies to explore their possible common underlying etiology PURPOSE : Estimates of insomnia in breast cancer patients are high , with reports of poor sleep lasting years after completion of cancer treatment . This r and omized controlled crossover pilot study looked at the effects of individual cognitive behavioral therapy for insomnia ( IND-CBT-I ) on sleep in breast cancer survivors . PATIENTS AND METHODS : Twenty-one participants were r and omly assigned to either a treatment group ( six weekly IND-CBT-I sessions followed by six weeks of follow up ) or a delayed treatment control group ( no treatment for six weeks followed by six weekly IND-CBT-I sessions ) . Of these , 14 participants completed the pilot study ( six in the treatment group and eight in the delayed treatment control group ) . RESULTS : Self-rated insomnia was significantly improved in the treatment group compared to the waiting period in the delayed treatment control group . The pooled pre-post-IND-CBT-I analyses revealed improvements in self-rated insomnia , sleep quality , and objective measures of sleep . CONCLUSIONS : These preliminary results suggest that IND-CBT-I is appropriate for improving sleep in breast cancer survivors . Individual therapy in a clinic or private practice may be a more practical option for this population as it is more easily accessed and readily available in an outpatient setting The purpose of this pilot study was to preliminarily examine the effects of an exercise program on the symptoms of fatigue , sleep disturbance , mood disturbance , symptom distress , and physical fitness for Thai women with breast cancer . Twenty-three eligible women were r and omly assigned to either an experimental group ( n = 11 ) or to a control group ( n = 12 ) . Data were collected and analyzed at baseline and again at 4 , 7 , and 10 weeks . At each time point , fatigue was measured at an expected high point during treatment . Participants in the exercise group demonstrated a trend toward improving the symptoms with mean score changes . Using generalized estimating equations analysis , a significant decrease in mood disturbance was found in the exercise group compared with control at 10 weeks ( β = 0.03 , P = 0.04 ) . The participants exhibited significantly longer 12-minute walk distance at 10 weeks than those in the control group ( t = 2.28 , P = 0.04 ) . These results indicate that exercise during adjuvant chemotherapy may be beneficial for Thai women with breast cancer This feasibility study aim ed at comparing psychosocial outcomes in head and neck cancer patients receiving the Nucare program  with a group of control subjects receiving no intervention .  A prospect i ve , nonr and omized study design was used . The Nucare program , a short-term psychoeducational coping strategies intervention , was the test intervention . Control subjects were matched to intervention subjects by cancer stage and time since cancer diagnosis . Outcomes were quality of life and depressive symptoms evaluated at baseline and 3 to 4 months later . One hundred thirty-eight subjects were recruited , and outcome data were available on 101 subjects . At outcome evaluation , compared with their baseline scores , the intervention group had improved physical and social functioning , global quality of life , fatigue , sleep disturbance , and depressive symptoms ; the control group showed no changes in quality of life or depressive symptoms . The results suggest that the Nucare program may improve quality of life and reduce depressive symptoms in head and neck cancer patients PURPOSE This study aim ed to examine mediators of fatigue response to an exercise intervention for breast cancer survivors in a pilot r and omized controlled trial . METHODS Postmenopausal breast cancer survivors ( n = 46 ; ≤stage 2 ) , off primary treatment , and reporting fatigue and /or sleep dysfunction were r and omized to a 3-month exercise intervention ( 160 min·wk of moderate-intensity aerobic walking , twice weekly resistance training with resistance b and s ) or control group . Six discussion group sessions provided behavioral support to improve adherence . Fatigue , serum cytokines , accelerometer physical activity , cardiorespiratory fitness , sleep dysfunction , and psychosocial factors were assessed at baseline and 3 months . RESULTS The exercise intervention effect sizes for fatigue were as follows : fatigue intensity d = 0.30 ( P = 0.34 ) , interference d = -0.38 ( P = 0.22 ) , and general fatigue d = -0.49 ( P = 0.13 ) . Using the Freedman-Schatzkin difference-in-coefficients tests , increase in fatigue intensity was significantly mediated by interleukin 6 ( IL-6 ) ( 82 % ) , IL-10 ( 94 % ) , IL-6/IL-10 ( 49 % ) , and tumor necrosis factor-α (TNF-α):IL-10 ( 78 % ) with reduced sleep dysfunction increasing the relationship between intervention and fatigue intensity rather than mediating intervention effects ( -88 % ) . Decrease in fatigue interference was mediated by sleep dysfunction ( 35 % ) , whereas IL-10 and pro-anti-inflammatory cytokine ratios increased the relationship between intervention and interference ( -25 % to -40 % ) . The reduction in general fatigue was significantly mediated by minutes of physical activity ( 76 % ) , sleep dysfunction ( 45 % ) , and physical activity enjoyment ( 40 % ) , with IL-10 ( -40 % ) and IL-6/IL-10 ( -11 % ) increasing the intervention-fatigue relationship . In the intervention group , higher baseline fatigue , anxiety , depression , and perceived exercise barrier interference predicted a greater decline in fatigue interference and /or general fatigue during the intervention . CONCLUSIONS Biobehavioral factors mediated and enhanced intervention effects on fatigue , whereas psychosocial factors predicted fatigue response . Further study is warranted to confirm our results and to improve underst and ing of relationships that mediate and strengthen the intervention-fatigue association OBJECTIVE This study aim ed to provide preliminary evidence on the efficacy of an early minimal cognitive-behavioural therapy for acute insomnia ( mCBT-I ) comorbid with cancer . METHOD Thirty-eight patients ( 92 % female ; Mage 57 ; all Caucasian ) with various types of cancer and having insomnia symptoms for less than 6 months were r and omized to a  self-administered mCBT-I condition ( n=20 ; 6 short booklets + 3 phone consultations with a psychologist , over 6 weeks ) or a no-treatment condition ( n=18 ) . Measures were completed at pre-treatment and post-treatment , as well as at 3- and 6-month follow-ups . RESULTS All sleep parameters and the average dosage of hypnotics were significantly improved from pre- to post-treatment among treated participants , but not in control participants . mCBT-I was also associated with a significantly greater reduction of anxiety and depression symptoms , maladaptive sleep habits , and erroneous beliefs about sleep , as well as with a significantly greater improvement of subjective cognitive functioning . A greater proportion of mCBT-I participants than controls met the criteria for a clinical remission at post-treatment . Therapeutic gains of mCBT-I were well sustained up to 6 months after the intervention . CONCLUSIONS This study supports the efficacy of an early minimal CBT-I to treat acute insomnia comorbid with cancer BACKGROUND To determine whether sleep quality and fatigue associated with breast cancer adjuvant chemotherapy treatments can be improved with behavioral therapy ( BT ) [ Individualized Sleep Promotion Plan ( ISPP ) ] including modified stimulus control , modified sleep restriction , relaxation therapy , and sleep hygiene . METHODS R and omized-controlled trial based on Piper Integrated Fatigue Model , 219 stages I-IIIA breast cancer patients . Prior to the initial chemotherapy treatment , BT participants developed an ISPP plan that was regularly reinforced and revised . Controls received healthy eating information and attention . Pittsburgh Sleep Quality Index ( PSQI ) , daily diary , actigraph , and Piper Fatigue Scale ( PFS ) data were collected 2 days prior , during the 7 days after each treatment , and 30 days after the last treatment . Repeated measures analysis of variance was used . RESULTS Prior to chemotherapy , participants reported mild fatigue and fairly poor sleep quality . All variables changed over time . A group by time interaction was found for sleep quality ( PSQI ) improving in the BT group . Diary revealed group differences on number of awakenings , minutes awake after sleep onset , and sleep efficiency . Fatigue ( PFS ) was similar between groups . CONCLUSIONS The BT group showed improved sleep quality over time and better sleep ( diary ) . Perceptions of improved sleep quality over time are not consistently associated with diary or actigraph , or result in lower fatigue This article describes the system for rating the quality of medical evidence  developed and used during creation of the Agency for Health Care Policy and Research -sponsored heart failure guideline . Previous approaches to rating evidence were not design ed for use in the setting of clinical practice guidelines . The present system is based on the tenet that flaws in research design are serious to the extent they threaten the validity of the results of studies . A taxonomy of major and minor flaws based on that tenet was developed for r and omized controlled trials and for cohort and medical registry studies . The use of the system is described in the context of two difficult clinical issues considered by the Panel : the role of coronary artery revascularization and the use of metoprolol BACKGROUND Insomnia is an important but often overlooked side effect of cancer . Dysfunctional sleep beliefs have been identified as an important perpetuating factor for insomnia . Mindfulness practice has been demonstrated to improve sleep quality but it is unknown whether these effects relate to changes in dysfunctional sleep beliefs . PURPOSE This study is a secondary analysis of a r and omized controlled trial comparing mindfulness-based cancer recovery ( MBCR ) to cognitive behavior therapy for insomnia ( CBT-I ) in cancer patients with insomnia . This present analysis compares program impact on mindfulness , dysfunctional sleep beliefs , and insomnia severity clinical cutoffs . METHODS Patients ( MBCR , n = 32 ; CBT-I , n = 40 ) were assessed at baseline , post-program , and 3-month follow-up . RESULTS Across both groups , patients showed improvements over time in acting with awareness ( P = .021 ) and not judging experiences ( P = .023 ) . Changes in dysfunctional sleep beliefs produced by the CBT-I group exceeded those produced by MBCR at post-program and follow-up ( P < .001 ) . Acting with awareness , non-judging , and non-reacting were the facets of mindfulness associated with an overall reduction in dysfunctional sleep beliefs . There were no significant differences between the MBCR and CBT-I groups in the percentage of patients exceeding insomnia severity clinical cutoffs at post-program or follow-up . CONCLUSIONS This study supports the use of both CBT-I and MBCR to reduce insomnia severity and suggests the development of mindfulness facets as a method of reducing dysfunctional sleep beliefs STUDY OBJECTIVES To investigate whether administration of an oral dose of 6 mg melatonin before bedtime perioperatively in breast cancer surgery could change sleep outcomes measured by actigraphy . METHODS This paper reports secondary outcomes from a double-blind , placebo-controlled , r and omized clinical trial where patients received 6 mg melatonin ( n = 27 ) or placebo ( n = 21 ) approximately 60 minutes before bedtime 3 nights preoperatively until at least one week postoperatively . Participants were monitored in the entire period with actigraphy , and were instructed to complete visual analogue scale ( VAS ) for sleep , and the Karolinska Sleepiness Scale ( KSS ) each morning . RESULTS Administration of 6 mg oral melatonin approximately 1 hour before bedtime result ed in significantly increased sleep efficiency and reduced wake after sleep onset for the entire 2-week postoperative period . No other significant differences for actigraphy determined sleep outcomes or subjective outcome parameters in the perioperative period were found between the groups . Overall , the patients sleep outcomes were within normal ranges and no participants had pathological sleep disturbances . CONCLUSIONS Melatonin significantly changed sleep efficiency and wake after sleep onset after surgery , but had no effects on other objective sleep outcomes or on subjective sleep quality ( VAS and KSS ) PURPOSE Persistent insomnia is a common complaint in cancer survivors , but is seldom satisfactorily addressed . The adaptation to cancer care of a vali date d , cost-effective intervention may offer a practicable solution . The aim of this study was to investigate the clinical effectiveness of protocol -driven cognitive behavior therapy ( CBT ) for insomnia , delivered by oncology nurses . PATIENTS AND METHODS R and omized , controlled , pragmatic , two-center trial of CBT versus treatment as usual ( TAU )  in 150 patients ( 103 females ; mean age , 61 years . ) who had completed active therapy for breast , prostate , colorectal , or gynecological cancer . The study conformed to CONSORT guidelines . Primary outcomes were sleep diary measures at baseline , post-treatment , and 6-month follow-up . Actigraphic sleep , health-related quality of life ( QOL ) , psychopathology , and fatigue were secondary measures . CBT comprised five , small group sessions across consecutive weeks , after a manualized protocol . TAU represented normal clinical practice ; the appropriate control for a clinical effectiveness study . RESULTS CBT was associated with mean reductions in wakefulness of 55 minutes per night compared with no change in TAU . These outcomes were sustained 6 months after treatment . St and ardized relative effect sizes were large for complaints of difficulty initiating sleep , waking from sleep during the night , and for sleep efficiency ( percentage of time in bed spent asleep ) . CBT was associated with moderate to large effect sizes for five of seven QOL outcomes , including significant reduction in daytime fatigue . There was no significant interaction effect between any of these outcomes and baseline demographic , clinical , or sleep characteristics . CONCLUSION CBT for insomnia may be both clinical ly effective and feasible to deliver in real world practice PURPOSE Sleep disruption is prevalent in patients with cancer and survivors , but the prevalence of insomnia , a distressing sleep disorder , in these population s has yet to be determined in large-scale studies . PATIENTS AND METHODS A total of 823 patients with cancer receiving chemotherapy ( mean age , 58 years ; 597 female patients ) reported on sleep difficulties in a prospect i ve study . RESULTS During day 7 of cycle 1 of chemotherapy , 36.6 % ( n = 301 ) of the patients with cancer reported insomnia symptoms , and 43 % ( n = 362 ) met the diagnostic criteria for insomnia syndrome . Patients with cancer younger than 58 years were significantly more likely to experience either symptoms of insomnia or insomnia syndrome ( chi(2 ) = 13.6 ; P = .0002 ) . Patients with breast cancer had the highest number of overall insomnia complaints . A significant positive association was found between symptoms of insomnia during cycles 1 and 2 of chemotherapy ( phi = .62 , P < .0001 ) , showing persistence of insomnia during the first two cycles of chemotherapy . Sixty percent of the patient sample reported that their insomnia symptoms remained unchanged from cycle 1 to cycle 2 . Those with insomnia complaints had significantly more depression and fatigue than good sleepers ( all P < .0001 ) . CONCLUSION The proportions of patients with cancer in this sample reporting symptoms of insomnia and meeting diagnostic criteria for insomnia syndrome during chemotherapy are approximately three times higher than the proportions reported in the general population . Insomnia complaints persist throughout the second chemotherapy cycle for the majority of patients with cancer in this study . Insomnia is prevalent , underrecognized , undermanaged , and understudied among patients with cancer receiving chemotherapy PURPOSE Our study examined whether mindfulness-based stress reduction ( MBSR ) is noninferior to cognitive behavioral therapy for insomnia ( CBT-I ) for the treatment of insomnia in patients with cancer . PATIENTS AND METHODS This was a r and omized , partially blinded , noninferiority trial involving patients with cancer with insomnia recruited from a tertiary cancer center in Calgary , Alberta , Canada , from September 2008 to March 2011 . Assessment s were conducted at baseline , after the program , and after 3 months of follow-up . The noninferiority margin was 4 points measured by the Insomnia Severity Index . Sleep diaries and actigraphy measured sleep onset latency ( SOL ) , wake after sleep onset ( WASO ) , total sleep time ( TST ) , and sleep efficiency . Secondary outcomes included sleep quality , sleep beliefs , mood , and stress . RESULTS Of 327 patients screened , 111 were r and omly assigned  (  CBT-I , n = 47 ; MBSR , n = 64 ) . MBSR was inferior to CBT-I for improving insomnia severity immediately after the program ( P = .35 ) , but MBSR demonstrated noninferiority at follow-up ( P = .02 ) . Sleep diary-measured SOL was reduced by 22 minutes in the CBT-I group and by 14 minutes in the MBSR group at follow-up . Similar reductions in WASO were observed for both groups . TST increased by 0.60 hours for CBT-I and 0.75 hours for MBSR . CBT-I improved sleep quality ( P < .001 ) and dysfunctional sleep beliefs ( P < .001 ) , whereas both groups experienced reduced stress ( P < .001 ) and mood disturbance ( P < .001 ) . CONCLUSION Although MBSR produced a clinical ly significant change in sleep and psychological outcomes , CBT-I was associated with rapid and durable improvement and remains the best choice for the nonpharmacologic treatment of insomnia Abstract The prevalence of sleep disturbance is high among cancer patients , and the sleep problems tend to last for years after the end of treatment . As part of a large r and omized controlled clinical trial ( the MICA trial , NCT00990977 ) of the effect of mindfulness-based stress reduction ( MBSR ) on psychological and somatic symptoms among breast cancer patients , the aim of the current study was to evaluate the effect of MBSR on the secondary outcome , ‘ sleep quality ’ . Material and methods . A total of 336 women operated on for breast cancer stage I – III 3–18 months previously were r and omized to MBSR ( n = 168 ) or treatment as usual ( n = 168 ) ; both groups received st and ard clinical care . The intervention consisted of an eight-week MBSR program ( psycho-education , meditation and gentle yoga ) . Sleep quality was assessed on the Medical Outcome Study sleep scale at baseline , after the intervention and at six- and 12-months ’ follow-up . Results . The mean sleep problem scores were significantly lower in the MBSR group than in controls immediately after the intervention . Quantile regression analyses showed that the effect was statistically significant only for the participants represented by the lower percentile of change between baseline and post-intervention , i.e. those who had more sleep problems ; the MBSR group had a significantly smaller increase in sleep problems than the control group . After the 12-month follow-up , there was no significant between-group effect of MBSR  on sleep quality in intention-to-treat analyses . Conclusion . MBSR had a statistically significant effect on sleep quality just after the intervention but no long-term effect among breast cancer patients . Future trials in which participation is restricted to patients with significant sleep problems are recommended for evaluating the effect of MBSR on sleep quality
BACKGROUND : New or worsening sleep‐wake disturbance ( SWD ) can occur throughout the cancer trajectory .
OBJECTIVES : The purpose of this article is to critically review available empirical evidence supporting the efficacy of interventions for SWD , highlighting new evidence since the 2006 and 2009 Putting Evidence Into Practice ( PEP ) SWD publications .