Supportive Care in Cancer

, Volume 27, Issue 10, pp 3777–3783 | Cite as

Screening for clinical insomnia in cancer patients with the Edmonton Symptom Assessment System-Revised: a specific sleep item is needed

  • Josée SavardEmail author
  • Hans Ivers
Original Article



We previously investigated the capacity of the original version of the Edmonton Symptom Assessment System-Revised (ESAS-r) and the Canadian Problem Checklist (CPP) to screen for clinical levels of insomnia in cancer patients. The original ESAS-r includes an item assessing drowsiness and an “other symptom” item, both of which are rated on a scale from 0 to 10, while the CPC has a sleep item, a box which is checked when this problem is present. Because none of these items showed an optimal screening capacity, we concluded that it would be best to add a specific 0–10 sleep item to the ESAS-r. This study assessed the capacity of this ESAS-r-sleep item to screen for clinical insomnia in patients with various cancer types.


A total of 392 patients with mixed cancer sites completed the ESAS-r as part of a routine screening procedure implemented in the radio-oncology department of L’Hôtel-Dieu de Québec (CHU de Québec-Université Laval). They also filled out the Insomnia Severity Index (ISI).


Using a score of 8 or greater on the ISI as the standard criterion for clinical insomnia, a score of 2 or higher on the ESAS-r-sleep item (50.8% of the patients) was the one that showed the best screening indices: sensitivity of 86.7%, specificity of 75.3%, positive predictive value of 71.9%, and negative predictive value of 88.6%. An area under the curve of 0.89 was found, which is excellent.


Adding a sleep item to the ESAS significantly improves screening of clinical insomnia in cancer patients.


Insomnia Sleep Screening Tiredness Fatigue Cancer ROC 


Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Mao JJ, Armstrong K, Bowman MA, Xie SX, Kadakia R, Farrar JT (2007) Symptom burden among cancer survivors: impact of age and comorbidity. J Am Board Fam Med 20:434–443. CrossRefGoogle Scholar
  2. 2.
    Hong F, Blonquist TM, Halpenny B, Berry DL (2016) Patient-reported symptom distress, and most bothersome issues, before and during cancer treatment. Patient Relat Outcome Meas 7:127–135. CrossRefGoogle Scholar
  3. 3.
    Cleeland CS, Zhao F, Chang VT, Sloan JA, O’Mara AM, Gilman PB, Weiss M, Mendoza TR, Lee JW, Fisch MJ (2013) The symptom burden of cancer: evidence for a core set of cancer-related and treatment-related symptoms from the Eastern Cooperative Oncology Group Symptom Outcomes and Practice Patterns study. Cancer 119:4333–4340. CrossRefGoogle Scholar
  4. 4.
    Ataseven B, Findte J, Harter P, Göke G, Holtschmidt J, Vogi C, Traut A, Vincenzo B, Vincent M, Florian H, Kuemmel S, Prader S, Sporkman M, Schneider S, du Bois A (2017) Change of patient perceptions of chemotherapy side effects in breast and ovarian cancer patients. Annueal conference of the European Society for Medical OncologyGoogle Scholar
  5. 5.
    Savard J, Villa J, Ivers H, Simard S, Morin CM (2009) Prevalence, natural course, and risk factors of insomnia comorbid with cancer over a 2-month period. J Clin Oncol 27:5233–5239CrossRefGoogle Scholar
  6. 6.
    Savard J, Villa J, Simard S, Ivers H, Morin CM (2011) Feasibility of a self-help treatment for insomnia comorbid with cancer. Psychooncology 20:1013–1019Google Scholar
  7. 7.
    Savard J, Morin CM (2001) Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 19:895–908CrossRefGoogle Scholar
  8. 8.
    Savard M, Savard J (2017) Cognitive-behavioral therapy for insomnia in cancer patients: an update of efficacy evidence and areas for future research. Curr Sleep Med Rep 3:66–75. CrossRefGoogle Scholar
  9. 9.
    Davidson JR, Feldman-Stewart D, Brennenstuhl S, Ram S (2007) How to provide insomnia interventions to people with cancer: insights from patients. Psychooncology 16:1028–1038. CrossRefGoogle Scholar
  10. 10.
    Ruel S, Savard J, Ivers H (2015) Insomnia and self-reported infections in cancer patients: an 18-month longitudinal study. Health Psychol 34:983–991. CrossRefGoogle Scholar
  11. 11.
    Daley M, Morin CM, LeBlanc M, Gregoire JP, Savard J (2009) The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep 32:55–64CrossRefGoogle Scholar
  12. 12.
    Bultz BD (2017) Lessons learned from the science of caring: extending the reach of psychosocial oncology: The International Psycho-Oncology Society 2016 Sutherland Award Lecture. Psychooncology 26:721–723. CrossRefGoogle Scholar
  13. 13.
    Travado L, Breitbart W, Grassi L, Fujisawa D, Patenaude A, Baider L, Connor S, Fingeret M (2017) 2015 President’s Plenary International Psycho-oncology Society: psychosocial care as a human rights issue-challenges and opportunities. Psychooncology 26:563–569. CrossRefGoogle Scholar
  14. 14.
    Bruera E, Kuehn N, Miller MJ, Selmser P, Macmillan K (1991) The Edmonton Symptom Assessment System (ESAS): a simple method for the assessment of palliative care patients. J Palliat Care 7:6–9CrossRefGoogle Scholar
  15. 15.
    Ashbury FD, Findlay H, Reynolds B, McKerracher K (1998) A Canadian survey of cancer patients’ experiences: Are their needs being met? J Pain Symptom Manag 16:298–306CrossRefGoogle Scholar
  16. 16.
    Fitch MI, Porter HB, Page BD (2008) Supportive care framework: a foundation for person-centered care. Pappin Communications Pembroke. Accessed 1 July 2018
  17. 17.
    Jacobsen PB, Donovan KA, Trask PC, Fleishman SB, Zabora J, Baker F, Holland JC (2005) Screening for psychologic distress in ambulatory cancer patients. Cancer 103:1494–1502CrossRefGoogle Scholar
  18. 18.
    Roth AJ, Kornblith AB, Batel-Copel L, Peabody E, Scher HI, Holland JC (1998) Rapid screening for psychologic distress in men with prostate carcinoma: a pilot study. Cancer 82:1904–1908CrossRefGoogle Scholar
  19. 19.
    Howell D, Oliver TK, Keller-Olaman S, Davidson J, Garland S., Savard J, Harris C, Aubin M, Olson K, Sussman J, Macfarlane J, Taylor C and the Sleep Disturbance Expert Panel on behalf of the Cancer Journey Advisory Group of the Canadian Partnership Against Cancer (2012) A pan-Canadian practice guideline: prevention, screening, assessment, and treatment of sleep disturbances in adults with cancer. Support Care Cancer 21:2695–2706Google Scholar
  20. 20.
    Savard J, Ivers H, Savard MH (2016) Capacity of the Edmonton Symptom Assessment System and the Canadian Problem Checklist to screen clinical insomnia in cancer patients. Support Care Cancer 24:4339–4344. CrossRefGoogle Scholar
  21. 21.
    Maxim L, Niebo R, Utell M (2014) Screening tests: a review with examples. Inhal Toxicol 26:811–828. CrossRefGoogle Scholar
  22. 22.
    Delgado-Guay M, Yennurajalingam S, Parsons H, Palmer JL, Bruera E (2011) Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer. J Pain Symptom Manag 41:819–827CrossRefGoogle Scholar
  23. 23.
    Hannon B, Dyck M, Pope A, Swami N, Banerjee S, Mak E, Bryson J, Rodin G, Ridley J, Lo C, Le LW, Zimmermann C (2015) Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer. J Pain Symptom Manag 49:945–952CrossRefGoogle Scholar
  24. 24.
    Kwon JH, Nam SH, Koh S, Hong YS, Lee KH, Shin SW, Hui D, Park KW, Yoon SY, Won JY, Chisholm G, Bruera E (2013) Validation of the Edmonton Symptom Assessment System in Korean patients with cancer. J Pain Symptom Manag 46:947–956CrossRefGoogle Scholar
  25. 25.
    Bernatchez MS, Savard J, Savard MH, Aubon M and Ivers H (in press) Sleep-wake difficulties in community-dwelling cancer patients receiving palliative care: Subjective and objective assessment. Palliat Support Care 1–11.
  26. 26.
    Blais MC, St-Hilaire A, Fillion L, De Serres M, Tremblay A (2014) What to do with screening for distress scores? Integrating descriptive data into clinical practice. Palliat Support Care 12:25–38CrossRefGoogle Scholar
  27. 27.
    Chang VT, Hwang SS, Feuerman M (2000) Validation of the Edmonton Symptom Assessment Scale. Cancer 88:2164–2171CrossRefGoogle Scholar
  28. 28.
    Feldstain A, Tomei C, Belanger M, Lebel S (2014) Screening for distress in patients with cancer: methodologic considerations. Curr Oncol 21:e330–e333CrossRefGoogle Scholar
  29. 29.
    Nekolaichuk C, Watanabe S, Beaumont C (2008) The Edmonton Symptom Assessment System: a 15-year retrospective review of validation studies (1991--2006). Palliat Med 22:111–122CrossRefGoogle Scholar
  30. 30.
    Bastien CH, Vallières A, Morin CM (2001) Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2:297–307CrossRefGoogle Scholar
  31. 31.
    Blais FC, Gendron L, Mimeault V, Morin CM (1997) Évaluation de l’insomnie: Validation de trois questionnaires. L’Encéphale 23:447–453Google Scholar
  32. 32.
    Savard MH, Savard J, Simard S, Ivers H (2005) Empirical validation of the Insomnia Severity Index in cancer patients. Psychooncology 14:429–441CrossRefGoogle Scholar
  33. 33.
    Trudel-Fitzgerald C, Savard J, Ivers H (2013) Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period. Ann Behav Med 45:329–337. CrossRefGoogle Scholar
  34. 34.
    Riedel BW, Lichstein KL (2000) Insomnia and daytime functioning. Sleep Med Rev 4:277–298CrossRefGoogle Scholar
  35. 35.
    Smith RA, Lack LC, Lovato N, Wright H (2015) The relationship between a night’s sleep and subsequent daytime functioning in older poor and good sleepers. J Sleep Res 24:40–46. CrossRefGoogle Scholar
  36. 36.
    Mitchell SA (2010) Cancer-related fatigue: state of the science. PM R 2:364–383. CrossRefGoogle Scholar
  37. 37.
    Ancoli-Israel S, Moore PJ, Jones V (2001) The relationship between fatigue and sleep in cancer patients: a review. Eur J Cancer Care 10:245–255CrossRefGoogle Scholar
  38. 38.
    Bower JE (2014) Cancer-related fatigue-mechanisms, risk factors, and treatments. Nat Rev Clin Oncol 11:597–609. CrossRefGoogle Scholar
  39. 39.
    American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders. American Psychiatric Publishing, ArlingtonCrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.School of PsychologyUniversité LavalQuébecCanada
  2. 2.CHU de Québec-Université Laval Research CenterQuébecCanada
  3. 3.Université Laval Cancer Research CenterQuébecCanada

Personalised recommendations