Sleep disruption and fatigue are ubiquitous among cancer patients and are sources of stress that may compromise treatment outcomes. Previously, we showed that a cognitive behavioral stress management (CBSM) intervention reduced anxiety and other stress-related processes in women undergoing primary treatment for breast cancer.
This study examined secondary outcomes from a CBSM intervention trial for women with early-stage breast cancer to test if CBSM would improve sleep quality and fatigue among these patients at a single site in southern Florida. CBSM-related effects have already been demonstrated for indicators of psychosocial adaptation (e.g., general and cancer-related anxiety).
Patients were randomized to CBSM (n= 120) or a 1-day psychoeducation control group (n= 120). The Pittsburgh Sleep Quality Index (PSQI) and Fatigue Symptom Inventory were completed prior to randomization and 6 and 12 months after the baseline assignment.
In latent growth analyses, women in CBSM reported greater improvements in PSQI sleep quality scores than controls, although there were no significant differences between conditions on PSQI total scores. Women in CBSM also reported greater reductions in fatigue-related daytime interference than controls, though there were no significant differences in changes in fatigue intensity. Changes in sleep quality were associated with changes in fatigue.
Future work may consider integrating sleep and fatigue content into stress management interventions for women with early-stage breast cancer.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Price excludes VAT (USA)
Tax calculation will be finalised during checkout.
Bower J. Behavioral symptoms in patients with breast cancer and survivors. J Clin Oncol. 2008;26(5):768–77.
Savard J, Morin C. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19(3):895–908.
Hrushesky W, Grutsch J, Wood P, et al. Circadian clock manipulation for cancer prevention and control and the relief of cancer symptoms. Integr Cancer Ther. 2009;8(4):387–97.
Montazeri A. Quality of life data as prognostic indicators of survival in cancer patients: an overview of the literature from 1982 to 2008. Health Qual Life Outcomes. 2009;7:102.
Langford D, Lee K, Miaskowski C. Sleep disturbance interventions in oncology patients and family caregivers: a comprehensive review and meta-analysis. Sleep Med Rev. 2012;16(5):397–414.
Berger A, Farr L, Kuhn B, et al. Values of sleep/wake, activity/rest, circadian rhythms, and fatigue prior to adjuvant breast cancer chemotherapy. J Pain Symptom Manag. 2007;33(4):398–409.
Irvine D, Vincent L, Graydon J, et al. The prevalence and correlates of fatigue in patients receiving treatment with chemotherapy and radiotherapy. A comparison with the fatigue experienced by healthy individuals. Cancer Nurs. 1994;17(5):367–78.
Ancoli-Israel S, Liu L, Marler M, et al. Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Support Care Cancer. 2006;14(3):201–9.
Liu L, Rissling M, Natarajan L, et al. The longitudinal relationship between fatigue and sleep in breast cancer patients undergoing chemotherapy. Sleep. 2012;35(2):237–45.
Minton O, Alexander S, Stone P. Identification of factors associated with cancer related fatigue syndrome in disease-free breast cancer patients after completing primary treatment. Breast Cancer Res Treat. 2012;136(2):513–20.
Mayo Clinic Staff. Fatigue. 2013 [cited 2013 September 3]; Available from: http://www.mayoclinic.com/health/fatigue/MY00120.
Shen J, Barbera J, Shapiro C. Distinguishing sleepiness and fatigue: focus on definition and measurement. Sleep Med Rev. 2006;10(1):63–76.
Banthia R, Malcarne V, Ko C, et al. Fatigued breast cancer survivors: the role of sleep quality, depressed mood, stage and age. Psychol Health. 2009;24(8):965–80.
Antoni M, Wimberly S, Lechner S, et al. Reduction of cancer-specific thought intrusions and anxiety symptoms with a stress management intervention among women undergoing treatment for breast cancer. Am J Psychiatry. 2006;163(10):1791–7.
Antoni M, Lechner S, Kazi A, et al. How stress management improves quality of life after treatment for breast cancer. J Consult Clin Psychol. 2006;74(6):1143–52.
Phillips K, Antoni M, Lechner S, et al. Stress management intervention reduces serum cortisol and increases relaxation during treatment for nonmetastatic breast cancer. Psychosom Med. 2008;70(9):1044–9.
Antoni M, Lechner S, Diaz A, et al. Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer. Brain Behav Immun. 2009;23(5):580–91.
Antoni M, Lutgendorf S, Blomberg B, et al. Cognitive–behavioral stress management reverses anxiety-related leukocyte transcriptional dynamics. Biol Psychiatry. 2012;71(4):366–72.
Demiralp M, Oflaz F, Komurcu S. Effects of relaxation training on sleep quality and fatigue in patients with breast cancer undergoing adjuvant chemotherapy. J Clin Nurs. 2010;19(7–8):1073–83.
Cannici J, Malcolm R, Peek L. Treatment of insomnia in cancer patients using muscle relaxation training. J Behav Ther Exp Psychiatry. 1983;14(3):251–6.
Davidson J, Waisberg J, Brundage M, et al. Nonpharmacologic group treatment of insomnia: a preliminary study with cancer survivors. Psychooncology. 2001;10(5):389–97.
Cohen M, Fried G. Comparing relaxation training and cognitive–behavioral group therapy for women with breast cancer. Res Soc Work Pract. 2007;17(3):313–23.
Davidson J, MacLean A, Brundage M, et al. Sleep disturbance in cancer patients. Soc Sci Med. 2002;54(9):1309–21.
Antoni M. Stress management intervention for women with breast cancer. Washington, DC: American Psychological Association Press; 2003.
Antoni M, Lehman J, Kilbourn K, et al. Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer. Health Psychol. 2001;20(1):20–32.
Beck A and Emery G. Cognitive therapy of anxiety and phobic disorders. Philadelphia, PA: Center for Cognitive Therapy; 1979.
Beck A, Rush A, Shaw B, et al. Cognitive therapy for depression. New York: Guilford Press; 1979.
Folkman S, Chesney M, McKusick L, et al. Translating coping theory into intervention. The social context of coping, ed. Eckenrode J; New York: Plenum; 1991.
Lutgendorf S, Antoni M, Ironson G, et al. Changes in cognitive coping skills and social support during cognitive behavioral stress management intervention and distress outcomes in symptomatic human immunodeficiency virus (HIV)-seropositive gay men. Psychosom Med. 1998;60(2):204–14.
Fillion L, Gagnon P, Leblond F, et al. A brief intervention for fatigue management in breast cancer survivors. Cancer Nurs. 2008;31(2):145–59.
Antoni M. Stress management intervention for women with breast cancer: participant workbook. Washington DC: American Psychological Association Press; 2003.
Buysse D, Reynolds C, Monk T, et al. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989;28(2):193–213.
Carpenter J, Andrykowski M. Psychometric evaluation of the Pittsburgh Sleep Quality Index. J Psychosom Res. 1998;45(1):5–13.
Buysse D, Hall M, Strollo P, et al. Relationships between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and clinical/polysomnographic measures in a community sample. J Clin Sleep Med. 2008;4(6):563–71.
Hann D, Jacobsen P, Azzarello L, et al. Measurement of fatigue in cancer patients: development and validation of the Fatigue Symptom Inventory. Qual Life Res. 1998;7(4):301–10.
Duncan T, Duncan S, Strycker L. An introduction to latent variable growth curve modeling: concepts, issues, and applications. Mahwah, NJ: Erlbaum; 1999.
Muthen B. Latent variable modeling with longitudinal and multi-level data. Sociological methodology, ed. Raferty A; Boston, MA: Blackwell; 1997.
Muthen L, Muthen B. Mplus user’s guide. Los Angeles CA: Muthen & Muthen; 1998.
Kline R. Principles and practice of structural equation modeling. 2nd ed. New York: Guilford Press; 2005.
Cohen J. A power primer. Psychol Bull. 1992;112(1):155–9.
Raudenbush S, Xiao-Feng L. Effects of study duration, frequency of observation, and sample size on power in studies of group differences in polynomial change. Psychol Methods. 2001;6(4):387–401.
Hayes A. Beyond Baron and Kenny: statistical mediation analysis in the new millenium. Commun Monogr. 2009;76(4):408–20.
Schulz K, Altman D, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. PLoS Med. 2010;7(3):e1000251.
Carver C. Measure of current status. 2006 [cited 2013 September 11]; available from: http://www.psy.miami.edu/faculty/ccarver/sclMOCS.html.
Morin C, Culbert J, Schwartz S. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Psychiatry. 1994;151(8):1172–80.
Savard J, Simard S, Ivers H, et al. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol. 2005;23(25):6083–96.
Desai K, Mao J, Su I, et al. Prevalence and risk factors for insomnia among breast cancer patients on aromatase inhibitors. Support Care Cancer. 2013;21(1):43–51.
McGrady A, Woerner M, Bernal G, et al. Effect of biofeedback-assisted relaxation on blood pressure and cortisol levels in normotensives and hypertensives. J Behav Med. 1987;10(3):301–10.
Viens M, De Koninck J, Mercier P, et al. Trait anxiety and sleep-onset insomnia: evaluation of treatment using anxiety management training. J Psychosom Res. 2003;54(1):31–7.
Lichstein K, Durrence H, Taylor D, et al. Quantitative criteria for insomnia. Behav Res Ther. 2003;41(4):427–45.
Kangas M, Bovbjerg D, Montgomery G. Cancer-related fatigue: a systematic and meta-analytic review of non-pharmacological therapies for cancer patients. Psychol Bull. 2008;134(5):700–41.
Goedendorp M, Gielissen M, Verhagen C, et al. Psychosocial interventions for reducing fatigue during cancer treatment in adults, in Cochrane Database of Systematic Reviews,2009.
Berger A, Kuhn B, Farr L, et al. One-year outcomes of a behavioral therapy intervention trial on sleep quality and cancer-related fatigue. J Clin Oncol. 2009;27(35):6033–40.
Kreps G, Sivaram R. Strategic health communication across the continuum of breast cancer care in limited-resource countries. Cancer. 2008;113(8 Suppl):2331–7.
Giedzinska A, Meyerowitz B, Ganz P, et al. Health-related quality of life in a multiethnic sample of breast cancer survivors. Ann Behav Med. 2004;28(1):39–51.
Edinger J, Wohlgemuth W, Radtke R, et al. Cognitive behavioral therapy for treatment of chronic primary insomnia: a randomized controlled trial. JAMA. 2001;285(14):1856–64.
The project was supported by National Cancer Institute Research Grant CA-064710 (ClinicalTrials.gov Identifier: NCT01422551). We thank Drs. Robert P. Derhagopian, Sharlene Weiss, Alan S. Livingstone, Frederick L. Moffat, Jr., Jodeen E. Powell, Eli Avisar, Joyce Slingerland, Stefan Glück, Dido Franceschi, and the Dade County American Cancer Society for their help in recruiting participants. We thank Janny M. Rogriguez for her support with recruitment, study management, and data entry. We also thank the participants for sharing their time and experiences with us.
Conflict of Interest
Dr. Antoni reports that he received royalties from books and related training materials that he has authored on cognitive behavioral stress management intervention in health psychology. All other authors reported no financial interests or potential conflicts of interest.
About this article
Cite this article
Vargas, S., Antoni, M.H., Carver, C.S. et al. Sleep Quality and Fatigue after a Stress Management Intervention for Women with Early-Stage Breast Cancer in Southern Florida. Int.J. Behav. Med. 21, 971–981 (2014). https://doi.org/10.1007/s12529-013-9374-2