Michael R. Irwin, MD
Underrecognized and inadequately managed, insomnia is a significant burden for many cancer survivors. Often persistent over several years following diagnosis and treatment, sleep problems negatively affect quality of life and elevate the risk of depression and anxiety. In this installment of The ASCO Post’s Integrative Oncology series, Dr. Irwin summarizes current research on utilizing tai chi, a mind-body approach involving movement and meditation, for managing insomnia in breast cancer survivors. The clinical implications of this safe, self--administered, and inexpensive modality are also presented.
Overview
Insomnia complaints are characterized by difficulties initiating sleep, frequent awakenings, and inability to return to sleep. When these sleep problems occur for at least three times per week, last for 3 months or more, and lead to daytime impairments such as fatigue and depressed mood, the clinical diagnosis of insomnia is fulfilled.1
The rate of insomnia in breast cancer survivors is nearly 30%, which is almost twice that of the general population.— Michael R. Irwin, MD
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Insomnia poses a significant public health concern, given its high prevalence, and this is especially true for cancer survivors. Indeed, the rate of insomnia in breast cancer survivors is nearly 30%, which is almost twice that of the general population.2-4 The disease burden of insomnia in cancer survivors is further magnified by the fact that insomnia persists and is found many years after cancer diagnosis and treatment.5
Among cancer survivors, chronic and persistent insomnia reduces quality of life, increases cancer-related fatigue and depression, increases inflammation, and possibly contributes to reduced survival by altering tumor progression.6 Given the growing number of cancer survivors, treatments that can be implemented and disseminated broadly are needed to address this significant behavioral comorbidity in cancer survivorship.
Why Tai Chi?
The American College of Physicians, as well as the American Academy of Sleep Medicine, recommend cognitive behavioral therapy for insomnia as the initial treatment of choice for adults with insomnia. It combines cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation to improve sleep outcomes. Cognitive behavioral therapy is found to be more effective than pharmacotherapy at improving sleep for both short- and long-term periods without the side effects found with sedative-hypnotic medications.7
However, despite its efficacy repeatedly demonstrated in multiple clinical trials for over 2 decades, cognitive behavioral therapy for insomnia is not widely used in medical and especially oncology settings, partly because it requires trained professionals and is expensive to administer, which together limit its access.7 Among cancer survivors, this limitation is particularly prominent, as oncologists may not be familiar with this therapy or have referral sources to implement this behavioral intervention in routine clinical practice or in oncology care.
Breast cancer survivors reported being committed to the practice of tai chi because they knew insomnia lowered their quality of life.— Michael R. Irwin, MD
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Salient in the treatment of insomnia in cancer survivors is targeting the mechanisms that precipitate and perpetuate sleep difficulties. Distress, associated with cancer diagnosis and treatment, contributes to the onset of insomnia and its persistence,5 which raises the possibility that innovative approaches targeting stress mechanisms may also have a role in the treatment of insomnia. Scalable, community accessible, and “outside-the-clinic” treatments that are known to target this distress include mind-body interventions such as mindfulness meditation and tai chi.
By combining slow physical activity and meditation, tai chi serves as a “movement meditation.” In community samples, as well as breast cancer survivors, mind-body treatments such as tai chi show a high level of acceptance; among breast cancer survivors, up to 50% report annual use of meditation or tai chi to promote health.8 Tai chi can be readily implemented in community settings, with available evidence suggesting it has broad benefits on multiple other health outcomes,9-13 including depression14 and fatigue,15 which are frequently comorbid in cancer survivors.16,17
Efficacy of Tai Chi in Treating Insomnia
In adults and older adults, tai chi is reported to improve insomnia symptoms18-20 and to have efficacy that is comparable to cognitive behavioral therapy for insomnia in the short term.12 Such findings are also similar to the ability of mindfulness meditation to improve outcomes of sleep, depression, and fatigue as compared with an active comparator, sleep hygiene education, in older adults.21 Whereas tai chi, as well as mindfulness meditation, yields benefits on sleep disturbance similar in magnitude to the gains achieved by cognitive behavioral therapy, it is not known whether tai chi is as effective as cognitive behavioral therapy in the treatment of insomnia; whether improvements in insomnia are maintained in the long term; and whether insomnia treatment gains with tai chi can be achieved in cancer survivors.
Comparative Trial
To address these questions, we designed a trial to test whether tai chi was noninferior to cognitive behavioral therapy for the treatment of insomnia among breast cancer survivors.22 Breast cancer survivors who were at least 6 months post cancer treatment were randomly assigned to receive either tai chi or cognitive behavioral therapy. Both treatments were delivered during a 3-month period, with evaluation of insomnia clinical response and insomnia remission after treatment and follow-up over 1 year.
This randomized, noninferiority trial found that both tai chi and cognitive behavioral therapy induced robust rates of insomnia treatment response, as indicated by marked clinical improvement (ie, complete or nearly complete remission of insomnia symptoms) that was comparable to reported treatment response for cognitive behavioral therapy for insomnia among adults and cancer survivors. Furthermore, tai chi was noninferior to cognitive behavioral therapy; both interventions appeared to be associated with equivalent rates of insomnia treatment response that were durably maintained during 1-year follow-up. Moreover, both treatment groups showed robust and similar improvements in depressive symptoms and fatigue; these symptoms are often neglected in insomnia treatment trials, but they are known to lead to insomnia.
There were no adverse effects associated with the practice of tai chi or cognitive behavioral therapy for insomnia.22 Breast cancer survivors continued to engage in the daily practice of tai chi, which indicates a high level of acceptability and adherence to this community-based treatment, necessary to support maintenance of the long-term benefits of this practice. Breast cancer survivors reported being committed to the practice of tai chi because they knew insomnia lowered their quality of life; some also expressed concern if insomnia persisted it might increase their risk for breast cancer recurrence.
Clinical Implications
Additionally, these practices have biologic effects and notably reduce systemic markers of inflammation such as C-reactive protein as well as inflammatory transcriptional profiles in older adults and breast cancer survivors.10-12 Given the link between inflammation and cancer incidence and progression, research on the molecular mechanisms of tai chi and other mind-body treatments may provide an evidence-based framework to understand the potential salutary effects of tai chi on cancer survivorship and to identify those cancer survivors who are most likely to show reversal of the inflammatory risk profile. ■
Dr. Irwin is Director, Cousins Center for Psychoneuroimmunology, Semel Institute for Neuroscience, and Professor of Psychology, Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California, Los Angeles.
DISCLOSURE: Dr. Irwin reported no conflicts of interest.
REFERENCES
1. American Psychiatric Association; American Psychiatric Association DSM-5 Task Force: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th Ed. Washington, DC: American Psychiatric Association; 2013.
2. Savard J, Villa J, Ivers H, et al: Prevalence, natural course, and risk factors of insomnia comorbid with cancer over a 2-month period. J Clin Oncol 27:5233-5239, 2009.
3. Savard J, Ivers H, Villa J, et al: Natural course of insomnia comorbid with cancer: An 18-month longitudinal study. J Clin Oncol 29:3580-3586, 2011.
4. Ohayon MM: Epidemiology of insomnia: What we know and what we still need to learn. Sleep Med Rev 6:97-111, 2002.
5. Irwin MR: Depression and insomnia in cancer: Prevalence, risk factors, and effects on cancer outcomes. Curr Psychiatry Rep 15:404, 2013.
6. Irwin MR: Why sleep is important for health: A psychoneuroimmunology perspective. Annu Rev Psychol 66:143-172, 2015.
7. Morin CM: Cognitive behavioral therapy for chronic insomnia: State of the science versus current clinical practices. Ann Intern Med 163:236-237, 2015.
8. DiGianni LM, Garber JE, Winer EP: Complementary and alternative medicine use among women with breast cancer. J Clin Oncol 20(18 suppl):34S-38S, 2002.
9. Wang C, Collet JP, Lau J: The effect of tai chi on health outcomes in patients with chronic conditions: A systematic review. Arch Intern Med 164:493-501, 2004.
10. Irwin MR, Olmstead R, Breen EC, et al: Tai Chi, cellular inflammation, and transcriptome dynamics in breast cancer survivors with insomnia: A randomized controlled trial. J Natl Cancer Inst 2014:295-301, 2014.
11. Irwin MR, Olmstead R, Breen EC, et al: Cognitive behavioral therapy and tai chi reverse cellular and genomic markers of inflammation in late-life insomnia: A randomized controlled trial. Biol Psychiatry 78:721-729, 2015.
12. Irwin MR, Olmstead R, Carrillo C, et al: Cognitive behavioral therapy vs. tai chi for late life insomnia and inflammatory risk: A randomized controlled comparative efficacy trial. Sleep 37:1543-1552, 2014.
13. Irwin MR, Olmstead R, Oxman MN: Augmenting immune responses to varicella zoster virus in older adults: A randomized, controlled trial of tai chi. J Am Geriatr Soc 55:511-517, 2007.
14. Lavretsky H, Alstein LL, Olmstead RE, et al: Complementary use of tai chi chih augments escitalopram treatment of geriatric depression: A randomized controlled trial. Am J Geriatr Psychiatry 19:839-850, 2011.
15. Campo RA, Agarwal N, LaStayo PC, et al: Levels of fatigue and distress in senior prostate cancer survivors enrolled in a 12-week randomized controlled trial of Qigong. J Cancer Surviv 8:60-69, 2014.
16. Miller AH, Ancoli-Israel S, Bower JE, et al: Neuroendocrine-immune mechanisms of behavioral comorbidities in patients with cancer. J Clin Oncol 26:971-982, 2008.
17. Irwin MR, Olmstead RE, Ganz PA, et al: Sleep disturbance, inflammation and depression risk in cancer survivors. Brain Behav Immun 30(suppl):S58-S67, 2013.
18. Irwin MR, Olmstead R, Motivala SJ: Improving sleep quality in older adults with moderate sleep complaints: A randomized controlled trial of tai chi chih. Sleep 31:1001-1008, 2008.
19. Li F, Fisher KJ, Harmer P, et al: Tai chi and self-rated quality of sleep and daytime sleepiness in older adults: A randomized controlled trial. J Am Geriatr Soc 52:892-900, 2004.
20. Raman G, Zhang Y, Minichiello VJ, et al: Tai chi improves sleep quality in healthy adults and patients with chronic conditions: A systematic review and meta-analysis. J Sleep Disord Ther 2:pii:141, 2013.
21. Black DS, O’Reilly GA, Olmstead R, et al: Mindfulness meditation and improvement in sleep quality and daytime impairment among older adults with sleep disturbances: A randomized clinical trial. JAMA Intern Med 175:494-501, 2015.
22. Irwin MR, Olmstead R, Carrillo C, et al: Tai chi chih compared with cognitive behavioral therapy for the treatment of insomnia in survivors of breast cancer: A randomized, partially blinded, noninferiority trial. J Clin Oncol 35:2656-2665, 2017.
