Guest Editor’s Note: Insomnia is common in patients with cancer and cancer survivors, and it has significant negative consequences. Cognitive behavior therapy for insomnia (CBT-I) is an effective approach for managing insomnia but is not easily available to many patients. In this installment of The ASCO Post’s Integrative Oncology series, Sheila N. Garland, PhD, R Psych; Samlau Kutana, BA; and Eric S. Zhou, PhD, summarize the work currently being done to expand patient access to CBT-I via digital health platforms.
Sheila N. Garland, PhD, R Psych
Samlau Kutana, BA
Eric S. Zhou, PhD
In 2017, I (Dr. Garland) co-wrote an article with Guest Editor Jun J. Mao, MD, MSCE, in The ASCO Post’s Integrative Oncology series entitled “Cognitive Behavior Therapy for Insomnia: Sleeping Well With Cancer and Beyond,” where we reviewed the importance of assessing and addressing insomnia in cancer survivors. Cognitive behavior therapy for insomnia (CBT-I) was introduced as the recommended treatment, and its treatment components and efficacy were described. Since then, the COVID-19 pandemic forced many medical providers to quickly adapt to virtual delivery models. Here, we review the steps being taken to expand access to CBT-I using digital health platforms and what this could mean for precision medicine.
Scope of the Problem
To begin, it is important to remember the prevalence of insomnia symptoms in individuals diagnosed with cancer is roughly 60%,1 which is two to three times higher than in the general population.2 Insomnia is characterized by difficulty falling and/or staying asleep that occurs more than three nights per week and that lasts longer than 3 months.3
Insomnia can present prior to a cancer diagnosis and persist for years after completion of cancer treatment, even as other areas of functioning improve.4 It is important to recognize that insomnia disorder is not simply a minor side effect of treatment, but it can significantly worsen physical and psychological recovery.5 This recognition has prompted the recommendation that insomnia disorder be diagnosed as such and treated as a comorbid condition.
CBT-I has demonstrated efficacy for use during and after cancer treatment. A 2022 meta-analysis of 22 randomized controlled trials conducted in cancer populations reported large and durable effects of treatment for reducing insomnia severity and improving sleep quality, along with improving fatigue, depression, anxiety, and quality of life.6 However, barriers such as lack of providers and poor insurance coverage make CBT-I inaccessible for many.7 This results in many patients with cancer and cancer survivors struggling with insomnia either receiving suboptimal treatment (eg, sleep hygiene) or not receiving treatment entirely.8
Digital Health Interventions
Digital health interventions have immense promise to increase treatment access. The effectiveness of digital CBT-I interventions delivered via apps or over the Internet has been established, with effect sizes similar to those achieved through traditional face-to-face approaches.9 When evaluated in cancer populations, digital CBT-I is equally efficacious. In a sample of 255 women with breast cancer, digital CBT-I produced large effect sizes for reducing insomnia.10
These interventions also hold promise for integration into current health-care models. In one of the few studies conducted in an oncology setting using a severity-stratified, stepped-care model, a 6-week digital CBT-I program was found to be noninferior to 6 weeks of face-to-face CBT-I in a group of 177 cancer survivors.11 This study demonstrates the utility of an alternative model of care to treat cancer-related insomnia that may be more easily implemented in routine cancer care than standard CBT-I.
Despite the excitement around the potential for digital health interventions for insomnia to improve the nights and days of patients with cancer and cancer survivors, we must not lose sight of the important research questions that remain. First, it is not clear whether a fully automated approach will work for all patients with cancer and cancer survivors. Personalized or precision medicine is designed to tailor treatments to the individual characteristics of a patient (eg, genetic, cultural, environmental, lifestyle factors) to optimize treatment engagement and response.
The only study to date to examine digital CBT-I treatment personalization found that Black American women were more likely to complete a culturally tailored digital CBT-I treatment than a standard program. Participants who completed treatment had greater sleep improvements than those who did not.12 It has yet to be determined whether the personalization of digital health interventions based on disease-specific variables for patients with cancer and cancer survivors would increase treatment adherence and engagement.
Guest Editor
Jun J. Mao, MD, MSCE
Dr. Mao is the Laurance S. Rockefeller Chair in Integrative Medicine and Chief of Integrative Medicine Service at Memorial Sloan Kettering Cancer Center, New York.
Next, although CBT-I programs typically include a cognitive element (eg, cognitive restructuring), a behavioral component (eg, sleep restriction), and sleep psychoeducation, evidence suggests that some treatment components may not be necessary for all patients to achieve clinically significant improvement in insomnia symptoms.13 As adherence is generally better for treatments that require less effort and engagement, and implementing each component in an automated treatment incurs additional development costs, researchers should seek to determine the optimal combination of digital CBT-I components, both at the group (eg, breast cancer survivors) and individual levels.
Finally, although fully automated interventions are significantly less resource-intensive, researchers must still account for the initial investment cost of developing these programs, as well as the costs of maintenance, data stewardship, and technical support.14 The main advantage of digital CBT-I is the ability to increase access for patients with cancer and cancer survivors; however, real-world uptake of this treatment may be significantly hampered by requiring patients to pay for the service. Potential solutions are to have an upfront cost of treatment that covers maintenance costs and is paid for by a patient’s insurance or an institutional license fee covered by the cancer center that provides access to all patients in their care.
Concluding Thoughts
We look forward to a new era of insomnia treatment in cancer care in which patients are able to receive a first-line recommended behavioral treatment, before being offered suboptimal treatments such as hypnotic medications.3 Addressing the issues related to personalization of treatment, treatment optimization, and implementation of digital CBT-I interventions has potential to greatly improve the physical and mental quality of life, as well as work productivity, absenteeism, and health-care utilization, of people diagnosed with cancer worldwide.
DISCLOSURE: Dr. Garland has received support from a Canadian Cancer Society Emerging Scholar Award, Survivorship (#707146). Mr. Kutana has received funds provided by the Canadian Cancer Society’s JD Irving – Limited Excellence in Cancer Research Fund. Dr. Zhou is supported by a Clinician Scientist Development Grant (CSDG-21-080-01 – CTPS) from the American Cancer Society; has received grant funding from Jazz Pharmaceuticals and Harmony Biosciences; and has received consulting fees from MindUP and Samsung for work unrelated to the content of this article.
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Dr. Garland works in the Department of Psychology, Discipline of Oncology, Faculty of Medicine at the Memorial University of Newfoundland, St. John’s, Canada. Mr. Kutana is a trainee in the Cancer Research Training Program of the Beatrice Hunter Cancer Research Institute. Dr. Zhou is Assistant Professor of Pediatrics and works in the Division of Sleep Medicine at Harvard Medical School, Boston.
