Sleep Promotion Program Can Relieve Some Postchemotherapy Fatigue Among Breast Cancer Patients

OMAHA—New research shows that some postchemotherapy fatigue in breast cancer patients is the result of disordered sleep and can be relieved by sleep intervention programs. At the 27th Annual Congress of the Oncology Nursing Society, Ann M. Berger, PhD, RN, AOCN, reported promising data from one such program that found that daily activity levels, fatigue, and quality of sleep all improved in cancer patients who went through a sleep intervention program. Dr. Berger is associate professor and advanced practice nurse at the University of Nebraska College of Nursing in Omaha.

"Although fatigue is often defined as tiredness that is not relieved by sleep, I believe that by promoting sleep we can modify fatigue in our cancer patients, as this study shows," Dr. Berger said.

Sleep problems and fatigue are almost universal among breast cancer patients during and after chemotherapy. Dr. Berger noted that sleep problems decrease daytime performance, increase anxiety and depression, and adversely affect fatigue levels, pain, immune function, and mental health. Despite these common problems, this is the first prospective study to test sleep interventions in cancer patients. "In fact, there are few data on sleep interventions in any disorder except insomnia," Dr. Berger said.

Four Program Components

In this pilot study, 21 patients who had surgery for stage I or II breast cancer and also had doxorubicin-based chemotherapy participated in a sleep intervention program. The program had four components:

• A sleep promotion plan. The patient selected three or four sleep-promoting behaviors from a list of 15 to use each day. These included such things as exercise at least 4 hours before bedtime, background "white noise" in the bedroom, no caffeine after noon, and sleeping in a cool room.

• Relaxation training. The patient selected one or two from a list of six relaxation techniques to use each day.

• Sleep restriction. The patient had a regular bedtime and morning "out of bed" time. Time in bed each night was restricted to 7 to 9 hours (usual need plus 1 hour). No more than three naps per day were permitted, with each nap limited to 45 minutes, and no naps within 4 hours of bedtime.

• Stimulus control. This included getting out of bed if the patient had not been able to get back to sleep for 20 minutes, going to a predetermined place in another room, reading or listening to quiet music, and returning to bed when feeling sleepy again.

Near-Normal Sleep

Patients were taken through program instructions before each chemotherapy and again at 30, 60, and 90 days after the last chemotherapy dose. Each patient education session was reinforced 1 week later.

Follow-up was 1 year after the first treatment. Efficacy was measured using a daily diary, the Pittsburgh Sleep Quality Index (PSQI), wrist Actigraphs that recorded activity levels for 5 minutes of every hour, and the Piper Fatigue Scale (PFS).

The women in this study achieved nearly normal sleep latency (time required to fall asleep), sleep efficiency, total minutes of rest, and ratings for waking up refreshed. "Since at least one-third of women usually report sleep problems after chemotherapy, this was very encouraging," Dr. Berger said.

The patients still had higher than normal numbers of nighttime awakenings and minutes awake during the night. Dr. Berger said that the normal number of nighttime awakenings is 2 to 6, whereas these patients had an average 10 awakenings identified by Actigraph up to 90 days after chemotherapy and still had 8.8 awakenings per night a full year after treatment. At that time, three-quarters of the patients were still awake longer than 30 minutes per night, and one-fifth longer than 60 minutes per night.

Compliance was high, with nearly 90% of patients adhering to all parts of the program except stimulus control. "In Nebraska in the winter, getting out of bed to go to another room is just not that attractive an idea," Dr. Berger said.

At 1 year, patients had daily activity levels 90% of those of healthy adults, and fatigue had stabilized at a mild level. "The intervention helped people fall asleep and obtain greater than 85% sleep efficiencies," Dr. Berger said.