S2 Episode 1: Diagnosing and Treating Sleep Disorders in Cancer Survivors

3 days ago 4

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Ann H. Partridge, MD, MPH: Hello. I'm Dr Ann Partridge. Welcome to season 2 of the Medscape InDiscussion podcast series on cancer survivorship. Today, we'll discuss sleep disorders and cancer survivorship. Why are they undertreated? What impact can they have on survival and quality of life? And most importantly, how can we connect our patients with the care or interventions they need? First, let me introduce my guest, who's going to go through all this with us, Dr Eric Zhou. Dr Zhou is on faculty at the Division of Sleep Medicine and an assistant professor of psychiatry at Harvard Medical School. He serves as a staff psychologist at the Dana-Farber Cancer Institute, where I get to work with him and refer my patients. Welcome to the Medscape InDiscussion cancer survivorship podcast, Eric.

Eric S. Zhou, PhD: Thank you, Ann. It's an absolute privilege to be here.

Partridge: I like to start off these sessions with a question, especially when I have someone that I'm supposed to know pretty well, because we've been working together for a number of years. What brought you to studying and treating insomnia in cancer patients and survivors?

Zhou: As you know, I am a psychologist by training. My first few clinical experiences were in what you would consider to be a standard outpatient psychological disorder center, where I got to see patients who presented with the typical mental health issues that you would imagine in the community. Things like depression or anxiety-related disorders.

What I found was that a lot of the work I was doing might move the needle a little bit. It's challenging, as you could imagine, to change somebody who might have been struggling with depression for years and years. In my internship, I had the opportunity to work with somebody who was interested in sleep medicine, and this was genuinely the first time in my professional career where I felt like I could change people's lives and I could do it quickly, and it felt so incredibly fulfilling that this became the path of my career. I'm incredibly lucky that I'm getting to do that today.

Partridge: That is so cool. I totally relate to the feeling and the gratitude one feels when you can actually fix a problem when a patient is facing it in the here and now because we all deal with so many chronic issues with our patients, although, of course, sleep can be a chronic issue. Let's delve in a little deeper. Tell me about sleep health. Why is it particularly important for cancer survivors?

Zhou: Sleep health is this multidimensional construct that encourages us to think about how patterns of sleep and wake affect our physical and our mental well-being. What's important is not just how many hours we're sleeping, but the quality and the timing of when that sleep occurs and whether that's actually aligned with our day-to-day responsibilities. This is particularly important for cancer survivors because they are far more likely than the average adult is to struggle with their sleep. One of the main reasons is because we know that sleep can be disturbed when life becomes stressful. At some point, every cancer survivor was told they had a potentially life-threatening illness. The majority of them have had to endure treatments that we know worsen sleep, sometimes for years on end, for example, as is the case with some of our breast cancer survivors on aromatase inhibitors.

Partridge: So sleep is a common problem for cancer survivors; why fix it? How does the disordered sleep ultimately impact the cancer survivors quality and quantity of life? And maybe we'll get into some of the more common or less common sleep disorders.

Zhou: It's a great question. We spend about a third of our lifetime sleeping, so I really do hope that evolution got this one right. Sleep is one of the foundations for good health, and not just for survivors but for everybody. We know that in the general population, problems like not getting enough sleep, having difficulty falling asleep or staying asleep, or sleep-disorder breathing are known risk factors for the development of everything from cardiovascular disease to obesity to depression and suicidal ideation. In cancer patients and survivors, we've seen really compelling evidence that this is one of the biggest contributors to decrements to their overall quality of life. There is really intriguing evidence that suggests that disrupted sleep can get under the skin and might ultimately be related to disease progression. Beyond what happens if you don't sleep well, perhaps the more important point to consider here is that most common sleep disorders can be effectively treated without medication or significant side effects.

Partridge: Which is really fantastic. We will get into that. But first, it makes sense that we should attend to this, both for the quality and potentially the quantity of life of our survivors. We cure people of a cancer, and then we affect them profoundly with not attending to this issue, which is underserved, I think. What are the common sleep disorders that cancer survivors face?

Zhou: Insomnia disorder and obstructive sleep apnea are likely to be the two most common sleep disorders in cancer survivors. I say most likely because we don't actually know the true prevalence of all sleep disorders in cancer populations. There's 60 different sleep disorders in the international classification of sleep disorders, some of which require polysomnography or a sleep study to diagnose. It's just not possible to do this at scale within the oncology setting. What we do know is that about 20%-30% of survivors will suffer from insomnia symptoms, with perhaps 10%-15% meeting diagnostic criteria for insomnia disorder. Here's where I want listeners to remember that the threshold for insomnia disorder is not nearly as high as some would imagine. It only requires that one of your survivors struggles with falling asleep or staying asleep a mere three times a week for 3 months or more. That's it. For obstructive sleep apnea, about 15% of your male survivors and about 5% of your female survivors are likely to meet diagnostic criteria. An important point here is that while there might not be considerable differences in prevalence rates for insomnia disorder by cancer diagnosis, head and neck cancer survivors are far more likely to have obstructive sleep apnea compared with other survivors because of their tumor and the subsequent treatment might affect their upper airway anatomy.

Partridge: Wow, that's fascinating. Some particular survivor groups are more likely to have these issues than others. Amazing that it is so prevalent. Let me ask you this, what's going on with this prioritization? Why aren't we paying enough attention to it? Why don't we have decent data? How can we ameliorate that? How can we prioritize it?

Zhou: It is a very big question for all of us. What can we do next? I think that that's something for the directors of survivorship programs, such as yourself, to think about. In terms of the reasons why it is that the sleep disorders are overlooked and sometimes inadequately screened and treated in the cancer setting, there's a lot of multifactorial reasons.

If we think about this at the systems level, cancer centers are built to treat cancer, not sleep disorders. As you might remember, we had surveyed survivorship programs at comprehensive cancer centers across the country, and only about half were consistently screening their patients for sleep disorders. Compounding this issue is that there is poor insurance reimbursement for some sleep-related services. This means that patients either face considerable out of pocket costs or long waitlists to see providers who might accept their insurance. At the provider level, as you and other oncologists and medical providers know, you might only have 15-30 minutes to meet with a survivor during one of your follow-up appointments. With all of the important treatment related sequelae you have to cover, sleep can understandably get left out of the discussion. Part of that is driven by priorities. Patients don't always prioritize sleep because they fear that treatment is only more medication, which they don't like. They also might be burned out from having had so many medical appointments over the course of their treatment journey. It just feels like one more thing on the pile.

Now, I want to raise an important point for oncologists and medical providers who are seeing survivors. If you are recommending that your survivor see a sleep specialist, I ask that you be extremely strong in your recommendation. I say this because a recent study was published, which breast cancer survivors were screened for common sleep disorders by a nurse, and if the screening revealed symptoms suggestive of a clinical sleep disorder, a member of that research study team called the survivor and scheduled them an intake appointment with the specialist. Despite literally being handheld to a sleep expert, less than 1 in 3 of those survivors in the study actually made it to that appointment.

Partridge: Fascinating. So patients are not even completely bought in to actually thinking their sleep disorder is either fixable or wanting to fix it. I see that in my practice too. I hadn't known about those data. Thank you for sharing. You always keep me up to speed on the latest and the greatest in sleep. It is fascinating, and we need to help patients prioritize this. We need to have our health systems prioritize this. This is a fixable problem, and it doesn't have to be medication. Let's talk about the behavioral and cognitive treatments and maybe a little bit on the pros and cons of that vs pharmacology. Because, of course, it's much easier for a doctor or a nurse or nurse practitioner to slap a benzo on someone or a hypnotic, as a band aid, of course, and get them through the tough times. But why do we recommend the behavioral techniques? Are they better or about the same? What do we think about that?

Zhou: There is an appropriate time and place for each treatment approach, with some evidence, actually, that sometimes, a combined approach may be best. If we look at them separately though, medications for insomnia should be prioritized when the need is immediate and there's a clear plan for how long that medication should be used for. For example, a patient who's anxious about a surgery that's scheduled in a couple of weeks and just started having sleep difficulties is the perfect candidate for medication. The tricky part here is making sure patients are thinking about an exit strategy for that medication while they're starting it. I often see in my clinic patients who've just remained on a sleep medication for years and years and now, they're psychologically dependent on it, even if it's actually doing very little to help their sleep. Now, the behavioral treatment that is recommended by the National Comprehensive Cancer Network (NCCN) is something called cognitive-behavioral therapy for insomnia (CBTI). This is an appropriate treatment path if the problem is longer-term. As I mentioned earlier, the diagnostic criteria for insomnia disorder is 3 or more months. So think along that timeline. This is an effective approach if that survivor is motivated to make positive health-related changes. Unlike medications, this approach requires them to put in the work and be diligent about the work for about a month or 2. This is valuable because CBTI teaches survivors how to fix the underlying causes of their insomnia, but it requires that they're committed to doing things that are better for them.

Partridge: As you know, I've sent a bunch of people for CBTI with you and through the different ways that you can deliver it. I know that it is a commitment. You've told me that it's not for the faint of heart. Tell us a little bit more about what it entails. Let's say I send a patient and they show up. It sounds like 1 in 3 patients will, even with firm recommendations. Tell me what you're going to do for that patient.

Zhou: CBTI is typically about five or six appointments spread out over a 3- to 4-month period. The most important element is something called sleep restriction, which involves matching the amount of time your survivor spends in their bed to the approximate amount of sleep that they actually need.

Almost always, insomnia patients spend more time in bed than they actually sleep. They do this because they feel miserable and believe that the path to feeling better is to get more sleep. In the short-term, this might actually make sense, like if someone had to wake up early for a flight. But because patients with insomnia repeatedly try to make up for poor sleep quality by getting more sleep, they wind up fragmenting their sleep.

It's important to understand that for a lot of patients, one of the drivers for this is their belief that they need 8 hours of sleep per night. I wish I had a nickel for every patient who said that. So they spend 8 or more hours in bed to try to get that 8 hours of sleep. The reality is that 8 hours is an average sleep duration for adults, and it doesn't mean that it's exactly what every single person needs.

Now, beyond the sleep restriction, other components of CBTI include stimulus control, which is limiting the use of the bed for sleep alone, for sleep hygiene, which are good habits that promote healthy sleep, like reducing electronics use in the evening, cognitive therapy, which is helping patients understand how some of the thoughts that they attach to sleep are not accurate and interfere with their sleep, and finally, relaxation exercises. I want to add one word of caution, which is that the most commonly given treatment for insomnia is sleep hygiene. Evidence has shown that by itself, it's not a successful independent monotherapy to treat insomnia. So please do not offer only sleep hygiene to patients.

Partridge: Thank you. I will make sure not to do that in clinic. I always do offer them to meet with you. But I think you bring up a good point. There's not a quick fix for real insomnia unless it's very short-term and time-limited, as you alluded to. So what should clinicians do? Assuming we're screening patients and that we identify a person who's suffering from insomnia, what should we do to address it and connect patients with care? I have you, but as you know, you're one person, and there's a waitlist for you. In the meantime, what should clinicians do other than giving patients sleep hygiene recommendations and advice? How should we manage this especially at centers where they don't have sleep center? I know there are some novel resources out there that people can take advantage of.

Zhou: The single best thing that a clinician can do is talk to their patients about sleep. Ask your survivors how their sleep is and ask them at every visit. They might not bring up any issues the first time you ask, but if it's truly a problem, they're going to mention it eventually. When they do — I hear what you're saying that for some providers without the resources of a large medical system, they may fear that they've opened up Pandora's box and don't know what to do. My thought here is for a referral network, you ideally want to have two good people or teams of people. First, you want to be connected with good sleep physicians. A good sleep physician will be instrumental in helping you manage your patient's sleep disorders, like sleep apnea or movement disorders or narcolepsy disorder, for example. Most medical centers have a good sleep lab, and that would be a good place to start. The American Academy of Sleep Medicine will be able to point you in the direction of board-certified or approved labs. The second group is a sleep psychologist, somebody like myself. A sleep psychologist is the person who is likely to lead the charge on treating insomnia disorder or circadian disorders among your survivors. The Society of Behavioral Sleep Medicine website lists providers by state. That can be an excellent resource for somebody working at a cancer center to become familiar with people in their state or local area.

Partridge: So you want to reach out to professionals and get a person evaluated. How do you advise our listeners to use apps like ShutEye?

Zhou: That's an excellent question. There are, as you've mentioned, Dr Partridge, a number of app-based and website-based fully automated treatments for insomnia disorder that deliver the core tenets of CBTI. The question of accessing them, sometimes, it is a bit of a challenge because there are companies that have tried to offer this and have insurance pay for them, and they haven't been extraordinarily successful at doing that.

My recommendation is that there are often clinical trials that are enrolling patients offering behavioral therapies for insomnia around the country, many of which are now offering this via telemedicine, so clinicians can enroll patients outside of a local area that might be worth taking a look into on clinicaltrials.gov. There are also, as I had mentioned, apps that offer CBTI, specifically, that are free of charge, that deliver the core components of this treatment. They aren't necessarily tailored to cancer survivors, but the core elements of what will help somebody sleep better are there. It would absolutely be silly of me not to mention that there are many books written for the consumer that you can purchase at any bookstore online or in person that describe all of the elements of this treatment. However, I caution folks in that your patient needs to be particularly self-motivated if they're going to be the kind of person that would benefit from bibliotherapy.

Partridge: Right? That would essentially be them figuring it out on their own. Ideally, you want to have a professional sleep clinician evaluate the patient and then harness the tools to help support the patient with the disorder that's found with regard to their sleep. It sounds pretty simple, although we know it's much more complex than that. What are we missing? We talked about the complexity of sleep, the multiconstructs that go into it, the expectations of patients, and how challenging it can be to get them to even want to fix it. What about in terms of making it more of a priority among systems? How do we help our clinicians listening to get their administrators to help support this kind of work? How do we advocate for our patients to get the services paid for?

Zhou: These are really big questions. I do know that here at Dana-Farber, one of the endeavors that I am working on right now is to try to cut out all of the middlemen or middlewomen, if you will. Within our patient medical record system, we are asking patients about how they're doing. These patient-reported outcomes are becoming increasingly important in healthcare, and when a patient is telling the system that they have these sleep disordered symptoms, I'm trying to send out to them a low-intensity intervention that can start to get the ball rolling on increasing in the patient's mind, the importance of these issues, and giving them strategies that are evidence-based to hopefully make their sleep better. Within our healthcare system, it really does, I fear, come down to a cost benefit. I don't think that there is enough compelling data to make the argument for many institutions to invest the resources that are necessary in order to be able to offer on-site, in-person, or telemedicine treatment for sleep disorders among cancer survivors. I do hope that that becomes something that institutions start to prioritize because, as I had mentioned earlier, it affects almost every domain of somebody's health. It absolutely is potentially life-limiting for some of our survivors.

Partridge: Thank you, Eric. Today we've talked with Dr Eric Zhou from the Dana-Farber Cancer Institute about the importance of sleep for cancer survivors and managing sleep disorders. Hopefully you're in a system where you can screen for it without too much work and or ask your patients over and over. They'll let you know ultimately and there are fixes out there so get them referred to a health professional and we'll all continue to partner with our primary care to make sure that this is paid attention to and that we have the services we need and prioritize sleep for cancer survivors. Thank you, Eric.

Thanks to all of you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on cancer survivorship. This is Dr Ann Partridge for the Medscape InDiscussion podcast.

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