Skip to main content

Evaluation and management of insomnia in women with breast cancer

Breast Cancer Research and Treatment volume 181, pages 269–277 (2020)Cite this article

Abstract

Purpose

Insomnia is a common issue among patients with breast cancer with a potentially devastating impact on quality of life. It can be caused or exacerbated by multiple disease and treatment-related factors. Despite the prevalence and impact of insomnia, it is rarely addressed systematically in the oncology clinic. We conducted a comprehensive review of insomnia to guide clinical care of patient’s with breast cancer and insomnia.

Methods

This manuscript reviews the prevalence, etiology, emerging science and both non-pharmacologic and pharmacologic options for treatment of insomnia among patients with breast cancer.

Results

Multiple factors contribute to insomnia among patients with breast cancer including endocrine therapy and hotflashes, pain and discomfort from local therapy, and fear of recurrence. If we do identify insomnia, there are treatment options and strategies available to help patients. In particular, there is now a considerable body of evidence supporting the use of psychosocial interventions and behavioral treatments, such as cognitive behavioral therapy for insomnia (CBT-I), yoga, and mind-body programs. It is also important for oncology providers to be educated regarding available pharmacologic therapies and emerging data for cannabis-based therapy.

Conclusion

This manuscript provides an up-to-date and comprehensive review of the prevalence, etiology, and treatment approaches available for insomnia for clinicians treating patients with breast cancer. We also address strategies and goals for cancer care delivery and future research.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

Fig. 1

References

  1. American Psychiatric Association (2013) In: Diagnostic and Statistical Manual of Mental Disorders, 5th edn. American Psychiatric Association, Washington, DC

  2. Zhou ES, Partridge AH, Syrjala KL, Michaud AL, Recklitis CJ (2017) Evaluation and treatment of insomnia in adult cancer survivorship programs. J Cancer Surviv 11(1):74–79

    PubMed  Google Scholar 

  3. Davidson JR, MacLean AW, Brundage MD, Schulze K (2002) Sleep disturbance in cancer patients. Soc Sci Med 54(9):1309–1321

    PubMed  Google Scholar 

  4. Savard J, Simard S, Blanchet J, Ivers H, Morin CM (2001) Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep 24(5):583–590

    CAS  PubMed  Google Scholar 

  5. Kyle SD, Morgan K, Espie CA (2010) Insomnia and health-related quality of life. Sleep Med Rev 14(1):69–82

    PubMed  Google Scholar 

  6. Bolge SC, Doan JF, Kannan H, Baran RW (2009) Association of insomnia with quality of life, work productivity, and activity impairment. Qual Life Res 18(4):415–422

    PubMed  Google Scholar 

  7. Sarsour K, Kalsekar A, Swindle R, Foley K, Walsh JK (2011) The association between insomnia severity and healthcare and productivity costs in a health plan sample. Sleep 34(4):443–450

    PubMed  PubMed Central  Google Scholar 

  8. Klink ME, Quan SF, Kaltenborn WT, Lebowitz MD (1992) Risk factors associated with complaints of insomnia in a general adult population Influence of previous complaints of insomnia. Arch Intern Med 152(8):1634–1637

    CAS  PubMed  Google Scholar 

  9. Schieber K, Niecke A, Geiser F, Erim Y, Bergelt C, Buttner-Teleaga A, Maatouk I, Stein B, Teufel M, Wickert M et al (2019) The course of cancer-related insomnia: don't expect it to disappear after cancer treatment. Sleep Med 58:107–113

    PubMed  Google Scholar 

  10. Fortner BV, Stepanski EJ, Wang SC, Kasprowicz S, Durrence HH (2002) Sleep and quality of life in breast cancer patients. J Pain Symptom Manag 24(5):471–480

    Google Scholar 

  11. Koopman C, Nouriani B, Erickson V, Anupindi R, Butler LD, Bachmann MH, Sephton SE, Spiegel D (2002) Sleep disturbances in women with metastatic breast cancer. Breast J 8(6):362–370

    PubMed  Google Scholar 

  12. Desai K, Mao JJ, Su I, Demichele A, Li Q, Xie SX, Gehrman PR (2013) Prevalence and risk factors for insomnia among breast cancer patients on aromatase inhibitors. Support Care Cancer 21(1):43–51

    PubMed  Google Scholar 

  13. Couzi RJ, Helzlsouer KJ, Fetting JH (1995) Prevalence of menopausal symptoms among women with a history of breast cancer and attitudes toward estrogen replacement therapy. J Clin Oncol 13(11):2737–2744

    CAS  PubMed  Google Scholar 

  14. Savard J, Davidson JR, Ivers H, Quesnel C, Rioux D, Dupere V, Lasnier M, Simard S, Morin CM (2004) The association between nocturnal hot flashes and sleep in breast cancer survivors. J Pain Symptom Manag 27(6):513–522

    Google Scholar 

  15. Cho NY, Kim S, Nowakowski S, Shin C, Suh S (2019) Sleep disturbance in women who undergo surgical menopause compared with women who experience natural menopause. Menopause 26(4):357–364

    PubMed  Google Scholar 

  16. Hatcher KM, Royston SE, Mahoney MM (2018) Modulation of circadian rhythms through estrogen receptor signaling. Eur J Neurosci 51:217

    PubMed  Google Scholar 

  17. Van Onselen C, Aouizerat BE, Dunn LB, Paul SM, West C, Hamolsky D, Lee K, Melisko M, Neuhaus J, Miaskowski C (2013) Differences in sleep disturbance, fatigue and energy levels between women with and without breast pain prior to breast cancer surgery. Breast 22(3):273–276

    PubMed  Google Scholar 

  18. Savard J, Morin CM (2001) Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 19(3):895–908

    CAS  PubMed  Google Scholar 

  19. Palesh OG, Collie K, Batiuchok D, Tilston J, Koopman C, Perlis ML, Butler LD, Carlson R, Spiegel D (2007) A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer. Biol Psychol 75(1):37–44

    PubMed  Google Scholar 

  20. Hall DL, Jimenez RB, Perez GK, Rabin J, Quain K, Yeh GY, Park ER, Peppercorn JM (2019) Fear of cancer recurrence: a model examination of physical symptoms, emotional distress, and health behavior change. J Oncol Pract 15(9):e787–e797

    PubMed  Google Scholar 

  21. Berrett-Abebe J, Cadet T, Pirl W, Lennes I (2015) Exploring the relationship between fear of cancer recurrence and sleep quality in cancer survivors. J Psychosoc Oncol 33(3):297–309

    PubMed  Google Scholar 

  22. Salo P, Sivertsen B, Oksanen T, Sjosten N, Pentti J, Virtanen M, Kivimaki M, Vahtera J (2012) Insomnia symptoms as a predictor of incident treatment for depression: prospective cohort study of 40,791 men and women. Sleep Med 13(3):278–284

    PubMed  Google Scholar 

  23. Siefert ML, Hong F, Valcarce B, Berry DL (2014) Patient and clinician communication of self-reported insomnia during ambulatory cancer care clinic visits. Cancer Nurs 37(2):E51–59

    PubMed  PubMed Central  Google Scholar 

  24. Engstrom CA, Strohl RA, Rose L, Lewandowski L, Stefanek ME (1999) Sleep alterations in cancer patients. Cancer Nurs 22(2):143–148

    CAS  PubMed  Google Scholar 

  25. Davidson JR, Feldman-Stewart D, Brennenstuhl S, Ram S (2007) How to provide insomnia interventions to people with cancer: insights from patients. Psychooncology 16(11):1028–1038

    PubMed  Google Scholar 

  26. Palesh O, Aldridge-Gerry A, Zeitzer JM, Koopman C, Neri E, Giese-Davis J, Jo B, Kraemer H, Nouriani B, Spiegel D (2014) Actigraphy-measured sleep disruption as a predictor of survival among women with advanced breast cancer. Sleep 37(5):837–842

    PubMed  PubMed Central  Google Scholar 

  27. Irwin M, McClintick J, Costlow C, Fortner M, White J, Gillin JC (1996) Partial night sleep deprivation reduces natural killer and cellular immune responses in humans. FASEB J 10(5):643–653

    CAS  PubMed  Google Scholar 

  28. Sephton SE, Sapolsky RM, Kraemer HC, Spiegel D (2000) Diurnal cortisol rhythm as a predictor of breast cancer survival. J Natl Cancer Inst 92(12):994–1000

    CAS  PubMed  Google Scholar 

  29. Kidwell KM, Harte SE, Hayes DF, Storniolo AM, Carpenter J, Flockhart DA, Stearns V, Clauw DJ, Williams DA, Henry NL (2014) Patient-reported symptoms and discontinuation of adjuvant aromatase inhibitor therapy. Cancer 120(16):2403–2411

    PubMed  PubMed Central  Google Scholar 

  30. Kakizaki M, Kuriyama S, Sone T, Ohmori-Matsuda K, Hozawa A, Nakaya N, Fukudo S, Tsuji I (2008) Sleep duration and the risk of breast cancer: the Ohsaki Cohort Study. Br J Cancer 99(9):1502–1505

    CAS  PubMed  PubMed Central  Google Scholar 

  31. McElroy JA, Newcomb PA, Titus-Ernstoff L, Trentham-Dietz A, Hampton JM, Egan KM (2006) Duration of sleep and breast cancer risk in a large population-based case-control study. J Sleep Res 15(3):241–249

    PubMed  Google Scholar 

  32. Wu AH, Wang R, Koh WP, Stanczyk FZ, Lee HP, Yu MC (2008) Sleep duration, melatonin and breast cancer among Chinese women in Singapore. Carcinogenesis 29(6):1244–1248

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Thompson CL, Li L (2012) Association of sleep duration and breast cancer OncotypeDX recurrence score. Breast Cancer Res Treat 134(3):1291–1295

    PubMed  PubMed Central  Google Scholar 

  34. Wang Y, Zhu X, Li L, Yi J, He J (2016) What factors affect the insomnia symptom trajectories in women with nonmetastatic breast cancer? J Pain Symptom Manag 52(6):850–858

    Google Scholar 

  35. Mcdonough A, Lei Y, Hagget D, Jimenez RB, Johnston K, Moy B, Spring L, Peppercorn J (2019) Implementation of a brief screening tool to identify needs of cancer survivors. J Clin Oncol. https://doi.org/10.1200/JCO.2019.37.15_suppl.e23075

    Article  PubMed  Google Scholar 

  36. Savard MH, Savard J, Simard S, Ivers H (2005) Empirical validation of the insomnia severity index in cancer patients. Psycho-Oncology 14(6):429–441

    PubMed  Google Scholar 

  37. Beck SL, Schwartz AL, Towsley G, Dudley W, Barsevick A (2004) Psychometric evaluation of the pittsburgh sleep quality index in cancer patients. J Pain Symptom Manag 27(2):140–148

    Google Scholar 

  38. Luyster FS, Choi J, Yeh CH, Imes CC, Johansson AE, Chasens ER (2015) Screening and evaluation tools for sleep disorders in older adults. Appl Nurs Res 28(4):334–340

    PubMed  PubMed Central  Google Scholar 

  39. Carney CE, Buysse DJ, Ancoli-Israel S, Edinger JD, Krystal AD, Lichstein KL, Morin CM (2012) The consensus sleep diary: standardizing prospective sleep self-monitoring. Sleep 35(2):287–302

    PubMed  PubMed Central  Google Scholar 

  40. Edinger JD, Hoelscher TJ, Webb MD, Marsh GR, Radtke RA, Erwin CW (1989) Polysomnographic assessment of DIMS: empirical evaluation of its diagnostic value. Sleep 12(4):315–322

    CAS  PubMed  Google Scholar 

  41. Kupfer DJ, Reynolds CF 3rd (1997) Management of insomnia. N Engl J Med 336(5):341–346

    CAS  PubMed  Google Scholar 

  42. Vincent N, Lionberg C (2001) Treatment preference and patient satisfaction in chronic insomnia. Sleep 24(4):411–417

    CAS  PubMed  Google Scholar 

  43. Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD (2016) Clinical guidelines committee of the American College of P: management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Ann Intern Med 165(2):125–133

    PubMed  Google Scholar 

  44. Morin CM, Culbert JP, Schwartz SM (1994) Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry 151(8):1172–1180

    CAS  PubMed  Google Scholar 

  45. Matthews EE, Berger AM, Schmiege SJ, Cook PF, McCarthy MS, Moore CM, Aloia MS (2014) Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial. Oncol Nurs Forum 41(3):241–253

    PubMed  Google Scholar 

  46. Dirksen SR, Epstein DR (2008) Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. J Adv Nurs 61(6):664–675

    PubMed  Google Scholar 

  47. Arnedt JT, Cuddihy L, Swanson LM, Pickett S, Aikens J, Chervin RD (2013) Randomized controlled trial of telephone-delivered cognitive behavioral therapy for chronic insomnia. Sleep 36(3):353–362

    PubMed  PubMed Central  Google Scholar 

  48. Dozeman E, Verdonck-de Leeuw IM, Savard J, van Straten A (2017) Guided web-based intervention for insomnia targeting breast cancer patients: feasibility and effect. Internet Interv 9:1–6

    PubMed  PubMed Central  Google Scholar 

  49. Atema V, van Leeuwen M, Kieffer JM, Oldenburg HSA, van Beurden M, Gerritsma MA, Kuenen MA, Plaisier PW, Lopes Cardozo AMF, van Riet YEA et al (2019) Efficacy of internet-based cognitive behavioral therapy for treatment-induced menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Clin Oncol 37(10):809–822

    PubMed  Google Scholar 

  50. Savard J, Ivers H, Savard MH, Morin CM (2016) Long-term effects of two formats of cognitive behavioral therapy for insomnia comorbid with breast cancer. Sleep 39(4):813–823

    PubMed  PubMed Central  Google Scholar 

  51. Vargas S, Antoni MH, Carver CS, Lechner SC, Wohlgemuth W, Llabre M, Blomberg BB, Gluck S, DerHagopian RP (2014) Sleep quality and fatigue after a stress management intervention for women with early-stage breast cancer in southern Florida. Int J Behav Med 21(6):971–981

    PubMed  PubMed Central  Google Scholar 

  52. Garland SN, Carlson LE, Stephens AJ, Antle MC, Samuels C, Campbell TS (2014) Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: a randomized, partially blinded, noninferiority trial. J Clin Oncol 32(5):449–457

    PubMed  Google Scholar 

  53. Lengacher CA, Johnson-Mallard V, Post-White J, Moscoso MS, Jacobsen PB, Klein TW, Widen RH, Fitzgerald SG, Shelton MM, Barta M et al (2009) Randomized controlled trial of mindfulness-based stress reduction (MBSR) for survivors of breast cancer. Psycho-Oncology 18(12):1261–1272

    PubMed  Google Scholar 

  54. Nakamura Y, Lipschitz DL, Kuhn R, Kinney AY, Donaldson GW (2013) Investigating efficacy of two brief mind-body intervention programs for managing sleep disturbance in cancer survivors: a pilot randomized controlled trial. J Cancer Surviv 7(2):165–182

    PubMed  PubMed Central  Google Scholar 

  55. Payne JK, Held J, Thorpe J, Shaw H (2008) Effect of exercise on biomarkers, fatigue, sleep disturbances, and depressive symptoms in older women with breast cancer receiving hormonal therapy. Oncol Nurs Forum 35(4):635–642

    PubMed  Google Scholar 

  56. Rogers LQ, Fogleman A, Trammell R, Hopkins-Price P, Vicari S, Rao K, Edson B, Verhulst S, Courneya KS, Hoelzer K (2013) Effects of a physical activity behavior change intervention on inflammation and related health outcomes in breast cancer survivors: pilot randomized trial. Integr Cancer Ther 12(4):323–335

    CAS  PubMed  Google Scholar 

  57. Mustian KM, Sprod LK, Janelsins M, Peppone LJ, Palesh OG, Chandwani K, Reddy PS, Melnik MK, Heckler C, Morrow GR (2013) Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. J Clin Oncol 31(26):3233–3241

    PubMed  PubMed Central  Google Scholar 

  58. Huang MI, Nir Y, Chen B, Schnyer R, Manber R (2006) A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality. Fertil Steril 86(3):700–710

    PubMed  Google Scholar 

  59. Guo J, Wang LP, Liu CZ, Zhang J, Wang GL, Yi JH, Cheng JL (2013) Efficacy of acupuncture for primary insomnia: a randomized controlled clinical trial. Evid Based Complement Alternat Med 2013:163850

    PubMed  PubMed Central  Google Scholar 

  60. Koffel E, Bramoweth AD, Ulmer CS (2018) Increasing access to and utilization of cognitive behavioral therapy for insomnia (CBT-I): a narrative review. J Gen Intern Med 33(6):955–962

    PubMed  PubMed Central  Google Scholar 

  61. Online Options for Insomnia Therapy [https://www.sleepreviewmag.com/sleep-treatments/behavioral-sleep-medicine/cognitive-behavioral-therapy/online-options-insomnia-therapy/]. Accessed 1 Apr 2020

  62. Morin CM, Koetter U, Bastien C, Ware JC, Wooten V (2005) Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial. Sleep 28(11):1465–1471

    PubMed  Google Scholar 

  63. Chen WY, Giobbie-Hurder A, Gantman K, Savoie J, Scheib R, Parker LM, Schernhammer ES (2014) A randomized, placebo-controlled trial of melatonin on breast cancer survivors: impact on sleep, mood, and hot flashes. Breast Cancer Res Treat 145(2):381–388

    CAS  PubMed  PubMed Central  Google Scholar 

  64. Holbrook AM, Crowther R, Lotter A, Cheng C, King D (2000) Meta-analysis of benzodiazepine use in the treatment of insomnia. CMAJ 162(2):225–233

    CAS  PubMed  PubMed Central  Google Scholar 

  65. Buysse DJ (2013) Insomnia. JAMA 309(7):706–716

    CAS  PubMed  PubMed Central  Google Scholar 

  66. Huedo-Medina TB, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN (2012) Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the food and drug administration. BMJ 345:e8343

    PubMed  PubMed Central  Google Scholar 

  67. Yi XY, Ni SF, Ghadami MR, Meng HQ, Chen MY, Kuang L, Zhang YQ, Zhang L, Zhou XY (2018) Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med 45:25–32

    PubMed  Google Scholar 

  68. Belendiuk KA, Babson KA, Vandrey R, Bonn-Miller MO (2015) Cannabis species and cannabinoid concentration preference among sleep-disturbed medicinal cannabis users. Addict Behav 50:178–181

    PubMed  Google Scholar 

  69. Kuhathasan N, Dufort A, MacKillop J, Gottschalk R, Minuzzi L, Frey BN (2019) The use of cannabinoids for sleep: A critical review on clinical trials. Exp Clin Psychopharmacol 27(4):383–401

    PubMed  Google Scholar 

  70. Babson KA, Sottile J, Morabito D (2017) Cannabis, cannabinoids, and sleep: a review of the literature. Curr Psychiatry Rep 19(4):23

    PubMed  Google Scholar 

Download references

Funding

The authors received no funding for this manuscript.

Author information

Affiliations

  1. Massachusetts General Hospital Cancer Center, 55 Fruit St, Boston, MA, 02114, USA

    Agnes Kwak, Jamie Jacobs, Dana Haggett, Rachel Jimenez & Jeffrey Peppercorn

  2. MGH Cancer Survivorship Program, Massachusetts General Hospital, Harvard Medical School, Boston, USA

    Jeffrey Peppercorn

Authors
  1. Agnes Kwak
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jamie Jacobs
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Dana Haggett
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Rachel Jimenez
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jeffrey Peppercorn
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jeffrey Peppercorn.

Ethics declarations

Conflict of interest

Author JP has received research grants from Pfizer. Author JP has consulted for Athenex. Author JP’s spouse is an employee of GlaxoSmithKline. No other author has a conflict of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Kwak, A., Jacobs, J., Haggett, D. et al. Evaluation and management of insomnia in women with breast cancer. Breast Cancer Res Treat 181, 269–277 (2020). https://doi.org/10.1007/s10549-020-05635-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10549-020-05635-0

Keywords

  • Insomnia
  • Breast cancer
  • Cognitive behavioral therapy
  • Review
  • Survivorship