Helping lung cancer patients beat insomnia

BUFFALO, N.Y. — It is estimated that anywhere from 50 to 80 percent of persons diagnosed with lung cancer experience severe insomnia that may persist for an average of eight years after the initial diagnosis.

Sleeplessness in lung cancer patients is related to a blend of pre-existing habits and conditions, as well as treatments specific to lung cancer, including a history of smoking, pre-existing chronic obstructive pulmonary disease (COPD) and the effects of lung cancer surgery, specifically partial lung removal and the postoperative radiotherapy that may follow. These treatments and conditions can result in anxiety, pain, cough and impaired breathing that make it difficult to fall asleep and to stay asleep.

To date, little research exists on strategies to reduce insomnia in lung cancer patients.

But Grace Dean, PhD, RN, assistant professor of nursing at the University at Buffalo who has studied fatigue in patients with cancer beginning in the late 1980s, is hoping to find ways to help patients solve this problem — and not always with sleeping medication.

Dean is the primary investigator on a $300,000 National Institutes of Health (NIH) grant to study cognitive behavior therapy techniques for lung cancer survivors who suffer from sleeplessness related to their diagnosis. The study, “Translating Cognitive Behavior Therapy-Insomnia (CBT-I) for Lung Cancer into Practice: A randomized controlled trial (RCT),” will run from September 2013 through August 2015.

Dean says the importance of sleep to health and well-being cannot be underestimated.

“Sleep is an absolute basic human necessity, like eating, drinking and breathing, but is often overlooked and not assessed unless the lack of it is determined to be severe,” she says. “Chronic sleep deficiency leads to increased risks for heart disease, kidney disease, hypertension, obesity, diabetes and depression.”

Preliminary work by Dean and her co-investigators leading up to the current grant suggests that lung cancer patients who have chronic insomnia may benefit from cognitive behavior therapy.

“We have designed a group intervention using cognitive behavior therapy for insomnia techniques to be delivered by nurses and that we will test on patients who are at least six weeks postop from Stage I/II, non-small cell lung cancer surgery,” she says. “If the intervention is significantly better than the control, we will pursue funding to teach this intervention to bedside nurses in the clinical setting.”

CBT-I, says Dean, uses the following techniques to improve sleep:

• Sleep hygiene — establishing a bedtime routine to wind down for sleep by limiting stimulants, for example
• Sleep restriction — limiting time in bed to increase sleep pressure
• Stimulus control — associating bed/bedroom with sleep and sex only; no TV, reading, texting, etc.
• Cognitive therapy — eliminating negative thoughts and worries related to sleep
• Introduction of relaxation techniques

Although all of the above techniques are essential to CBT-I, Dean says the two most important are sleep restriction and stimulus control.

She points out that CBT-I results in clinically significant improvements in insomnia symptoms without the negative effects commonly reported with some hypnotic (sleeping) medications, such as slowed respirations in patients who already may be dealing with oxygen deficiency.  

“Studies show that patients and physicians are more likely to use hypnotics as the first line of treatment for insomnia symptoms,” she says. “Despite the effectiveness of CBT-I and the need for this therapy, CBT-I is not clinically accessible for most cancer patients.”

Why nurses?

Dean says nurses are uniquely positioned to deliver CBT-I for a variety of reasons. They have access to patients and, as members of the most trusted of 21 professions according to Gallup polls since 1999, patients are positively influenced by them.

“Indeed, nurses have received the highest ranking every year except in 2001, when fire fighters received top honors,” she says. “Furthermore, for some individuals, having a nurse deliver the therapy is less stigmatizing than seeing a psychologist or psychiatrist, no matter the reason.”

Dean’s co-investigators on the grant are Suzanne Dickerson, DNS, RN, and Carla Jungquist, PhD, RN, from the UB School of Nursing; Lynn Steinbrenner, MD, from the Veterans Administration, Western New York Medical Center; Joseph Lucke, PhD, from UB’s Research Institute on Addictions; Nadine Fisher, EdD, from the UB Department of Rehabilitation Science; and Samjot Dhillon, MD; Hongbin Chen, MD; and Elizabeth Dexter, MD, from Roswell Park Cancer Institute.