Sleep-Wake Disturbances in People With Cancer Part I: An Overview of Sleep, Sleep Regulation, and Effects of Disease and Treatment

Catherine Vena

Kathy P. Parker

Mary Cunningham

Jane C. Clark

Sandra W. McLeskey

ONF 2004, 31(4), 735-746. DOI: 10.1188/04.ONF.735-746

Purpose/Objectives: To provide an overview of normal sleep, describe common sleep disorders, and discuss underlying sleep regulatory processes and how cancer, cancer treatment, and associated patient responses may adversely affect sleep.

Data Sources: Published peer-reviewed articles and textbooks.

Data Synthesis: The duration, structure, and timing of sleep have a profound impact on health, well-being, and performance. Patients with cancer may be at risk for disturbances in sleeping and waking resulting from disease- and nondisease-related circumstances that interfere with normal sleep regulation, including demographic, lifestyle, psychological, and disease- and treatment-related factors.

Conclusions: Patients with cancer are at high risk for sleep-wake disturbances.

Implications for Nursing: An understanding of normal sleep, sleep pathology, and the factors that can precipitate sleep disturbance provides a context for nurses to interpret sleep complaints in their patients, evaluate responses to sleep-promoting interventions, and guide decision making regarding referrals.

Jump to a section

    References

    Aldrich, M.S. (1999). Sleep medicine. New York: Oxford University Press.

    American Academy of Sleep Medicine. (2001). The international classification of sleep disorders revised. Rochester, MN: Author.

    American Cancer Society. (2004). Cancer facts and figures 2004. Atlanta, GA: Author.

    American Sleep Disorders Association. (1995). Practice parameters for the use of actigraphy in the clinical assessment of sleep disorders. Sleep, 18, 285-287.

    Ancoli-Israel, S. (2000). Actigraphy. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 1295-1301). Philadelphia: Saunders.

    Ancoli-Israel, S., Kripke, D.F., Klauber, M.R., Mason, W.J., Fell, R., & Kaplan, O. (1991). Sleep-disordered breathing in community-dwelling elderly. Sleep, 14, 486-495.

    Ardestani, S., Inserra, P., Solkoff, D., & Watson, R.R. (1999). The role of cytokines and chemokines on tumor progression: A review. Cancer Detection and Prevention, 23, 215-225.

    Avery, D.H., Wildschiodtz, G., Smallwood, R.G., Martin, D., & Rafaelsen, O.J. (1986). REM latency and core temperature relationships in primary depression. Acta Psychiatrica Scandinavica, 74, 269-280.

    Baekland, F., & Hoy, P. (1971). Reported versus recorded sleep characteristics. Archives of General Psychiatry, 24, 548-551.

    Banks, W.A., Kastin, A.J., & Broadwell, R.D. (1995). Passage of cytokines across the blood-brain barrier. Recent Progress in Neuroimmunomodulation, 2, 241-248.

    Bartsch, C., Bartsch, H., Fluchter, S.H., Attanasio, A., & Gupta, D. (1985). Evidence for modulation of melatonin secretion in men with benign and malignant tumors of the prostate: Relationship with pituitary hormones. Journal of Pineal Research, 2, 121-132.

    Bartsch, C., Bartsch, H., Fuchs, U., Lippert, T.H., Bellmann, O., & Gupta, D. (1989). Stage-dependent depression of melatonin in patients with primary breast cancer: Correlation with prolactin, thyroid stimulating hormone, and steroid receptors. Cancer, 64, 426-433.

    Bartsch, C., Bartsch, H., Schmidt, A., Bichler, K.H., & Fluchter, S.H. (1992). Melatonin and 6-sulfatoxymealtonin circadian rhythms in serum and urine of primary prostate cancer patients: Evidence for reduced pineal activity and relevance of urinary determinations. Clinica Chimica Acta, 209, 153-167.

    Bedard, M.A., Montplaisir, J., Richer, F., Rouleau, I., & Malo, J. (1991). Obstructive sleep apnea syndrome: Pathogenesis of neuropsychological deficits. Journal of Clinical and Experimental Neuropsychology, 13, 950-964.

    Belka, C., Budach, W., Kortman, R.D., & Bamberg, M. (2001). Radiationinduced CNS toxicity—Molecular and cellular mechanisms. British Journal of Cancer, 85, 1233-1239.

    Benca, R.M. (2000). Mood disorders. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 1140-1157). Philadelphia: Saunders.

    Benca, R.M., & Quintans, J. (1997). Sleep and host defenses: A review. Sleep, 20, 1027-1037.

    Berger, A.M., & Farr, L. (1999). The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue. Oncology Nursing Forum, 26, 1663-1671.

    Berger, A.M., & Higginbotham, P. (2000). Correlates of fatigue during and following adjuvant breast cancer chemotherapy: A pilot study. Oncology Nursing Forum, 27, 1443-1448.

    Beszterczey, A., & Lipowski, Z.J. (1977). Insomnia in cancer patients [Letter to the editor]. Canadian Medical Association Journal, 116, 355.

    Blazer, D.G., Hays, J.C., & Foley, D.J. (1995). Sleep complaints in older adults: A racial comparison. Journals of Gerontology: Series A, Biological Sciences and Medical Sciences, 50, M280-M284.

    Bliwise, D.L. (1989). Neuropsychological function and sleep. Clinics in Geriatric Medicine, 5, 381-394.

    Bliwise, D.L. (1999). Sleep and circadian rhythm disorders in aging and dementia. In F.W. Turek & P.C. Zee (Eds.)Regulation of sleep and circadian rhythms (pp. 487-525). New York: Marcel Dekker.

    Bliwise, D.L. (2000). Normal aging. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 26-42). Philadelphia: Saunders.

    Bonnet, M.H. (1985). Effect of sleep disruption on sleep, performance, and mood. Sleep, 8(1), 11-19.

    Borbely, A.A., & Achermann, P. (2000). Sleep homeostasis and models of sleep regulation. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 377-390). Philadelphia: Saunders.

    Borbely, A.A., & Wirz-Justice, A. (1983). Sleep, sleep deprivation and depression: A hypothesis derived from a model of sleep regulation. Human Neurobiology, 1, 205-210.

    Bottomley, A. (1998). Depression in cancer patients: A literature review. European Journal of Cancer Care, 7, 181-191.

    Breslau, N., Roth, T., Rosenthal, L., & Andreski, P. (1996). Sleep disturbance and psychiatric disorders: A longitudinal epidemiological study of young adults. Biological Psychiatry, 39, 411-418.

    Briones, B., Adams, N., Strauss, M., Rosenberg, C., Whalen, C., Carskadon, M., et al. (1996). Relationship between sleepiness and general health status. Sleep, 19, 583-588.

    Broeckel, J.A., Jacobsen, P.B., Horton, J., Balducci, L., & Lyman, G.H. (1998). Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 16, 1689-1696.

    Buysse, D.J., Browman, K.E., Monk, T.H., Reynolds, C.F.I., Fasiczka, A.L., & Kupfer, D.J. (1992). Napping and 24-hour sleep/wake patterns in healthy elderly and young adults. Journal of the American Geriatrics Society, 40, 779-786.

    Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193-213.

    Cagnacci, A., Elliott, J.A., & Yen, S.S.C. (1992). Melatonin: A major regulator of the circadian rhythm of core temperature in humans. Journal of Clinical Endocrinology and Metabolism, 75, 447-452.

    Campbell, S.S., & Zulley, J. (1989). Evidence for circadian influence on human slow wave sleep during daytime sleep episodes. Psychophysiology, 26, 580-585.

    Capuron, L., Ravaud, A., & Dantzer, R. (2000). Early depressive symptoms in cancer patients receiving interleukin 2 and/or interferon alfa-2b therapy. Journal of Clinical Oncology, 18, 2143-2151.

    Carli, G., Montesano, A., Rapezzi, S., & Paluffi, G. (1987). Differential effects of persistent nociceptive stimulation on sleep stages. Behavioural Brain Research, 26(2-3), 89-98.

    Carpenter, J.S., Shiva, G., Freedman, R.R., & Andrykowski, M.A. (2001). Circadian rhythm of objectively recorded hot flashes in postmenopausal breast cancer survivors. Menopause, 8, 181-188.

    Carskadon, M.A., & Dement, W.C. (2000). Normal human sleep: An overview. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Priniciples and practice of sleep medicine (3rd ed., pp. 15-25). Philadelphia: Saunders.

    Carskadon, M.A., & Rechtschaffen, A. (2000). Monitoring and staging human sleep. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Priniciples and practice of sleep medicine (3rd ed., pp. 1197-1215). Philadelphia: Saunders.

    Cleeland, C.S., Gonin, R., Hatfield, A.K., Edmonson, J.H., Blum, R.H., Stewart, J.A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer. New England Journal of Medicine, 330, 592-596.

    Cohen, R.A., & Albers, H.E. (1991). Disruption of human circadian and cognitive regulation following a discrete hypothalamic lesion: A case study. Neurology, 41, 726-729.

    Cole, R.J., Kripke, D.F., Gruen, W., Mullaney, D.J., & Gillan, J.C. (1992). Automatic sleep/wake identification from wrist activity. Sleep, 15, 461-469.

    Couzi, R.J., Helzlsouer, K.J., & Fetting, J.H. (1995). Prevalence of menopausal symptoms among women with a history of breast cancer and attitudes toward estrogen replacement therapy. Journal of Clinical Oncology, 13, 2737-2744.

    Czeisler, C.A., & Khalsa, S.S. (Eds.). (2000). The human circadian timing system and sleep-wake regulation (3rd ed.). Philadelphia: Saunders.

    Dement, W.C. (2000). History of sleep physiology and medicine. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 1-14). Philadelphia: Saunders.

    Derogatis, L.R., Morrow, G.R., Fettig, J., Penman, D., Piasetsky, S., Schmale, A.M., et al. (1983). The prevalence of psychiatric disorders among cancer patients. JAMA, 249, 751-757.

    Dietrich, B. (1997). Polysomnography in drug development. Journal of Clinical Pharmacology, 37(1, Suppl.), 70S-78S.

    Dinarello, C.A., & Bunn, P.A. (1997). Fever. Seminars in Oncology, 24, 288-298.

    Dinges, D., Pack, F., Williams, K., Gillen, K.A., Powell, J.W., Ott, G.E., et al. (1997). Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep, 20, 267-277.

    Dinges, D.F. (1989). The nature of sleepiness: Causes and consequences. In R.J. Strunkard & A. Baum (Eds.)Perspectives in behavioral medicine (pp. 147-180). Hillsdale, NJ: Lawrence Erlbaum.

    Donovan, M., Dillon, P., & McGuire, L. (1987). Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain, 30, 69-78.

    Dorrepaal, K.L., Aaronson, N.K., & van Dam, F.S. (1988). Pain experience and pain management among hospitalized cancer patients. Cancer, 63, 593-598.

    Drewes, A.M., Nielsen, K.D., Arendt-Nielson, L., Birket-Smith, L., & Hansen, L.M. (1997). The effect of cutaneous and deep pain on the electroencephalogram during sleep—An experimental study. Sleep, 20, 632-640.

    Dunlop, R.J., & Campbell, C.W. (2000). Cytokines and advanced cancer. Journal of Pain and Symptom Management, 20, 214-232.

    Edinger, J.D., Erwin, C.W., Fins, A.I., Marsh, G.R., & Krystal, A.D. (1995). Ambulatory cassette polysomnography: Findings from a large cohort of drug-free insomnia patients. Journal of Clinical Neurophysiology, 12, 302-309.

    El-Ad, B., & Korczyn, A.D. (1998). Disorders of excessive daytime sleepiness—An update. Journal of Neurological Sciences, 153, 192-202.

    Engstrom, C.A., Strohl, R.A., Rose, L., Lewandowski, L., & Stefanek, M.E. (1999). Sleep alterations in cancer patients. Cancer Nursing, 22, 143-148.

    Ericsson, A., Kovacs, K.J., & Sawchenko, P.E. (1994). A functional anatomical analysis of central pathways subserving the effects of interleukin-1 on stress-related neuroendocrine neurons. Journal of Neuroscience, 14, 897-913.

    Faithfull, S. (1991). Patients' experiences following cranial radiotherapy: A study of the somnolence syndrome. Journal of Advanced Nursing, 16, 939-946.

    Foley, D.J., Monjan, A.A., Brown, S.L., Simonsick, E.M., Wallace, R.B., & Blazer, D.G. (1995). Sleep complaints among elderly persons: An epidemiologic study of three communities. Sleep, 18, 425-432.

    Follenius, M., Brandenberger, G., Bandesapt, J.J., Libert, J.P., & Ehrhart, J. (1992). Nocturnal cortisol release in relation to sleep structure. Sleep, 15, 21-27.

    Ford, D.E., & Kamerow, D.B. (1989). Epidemiologic study of sleep disturbance and psychiatric disorders: An opportunity for prevention? JAMA, 262, 1479-1484.

    Friedman, J., Globus, G., & Huntley, A. (1977). Performance and mood during and after gradual sleep reduction. Psychophysiology, 14, 245-250.

    Ganguli, M., Reynolds, C.F., & Gilby, J.E. (1996). Prevalence and persistence of sleep complaints in rural older community sample: The MoVIES project. Journal of the American Geriatrics Society, 44, 778-784.

    Greenberg, D.B., Gray, J.L., Mannix, C.M., Eisenthal, S., & Carey, M. (1993). Treatment-related fatigue and serum interleukin-1 levels in patients during external beam irradiation for prostate cancer. Journal of Pain and Symptom Management, 8, 196-200.

    Hicks, R.A., Coleman, D.D., Ferrante, F., Sahatjian, M., & Hawkins, J. (1979). Pain thresholds in rats during recovery from REM sleep deprivation. Perceptual and Motor Skills, 48, 687-690.

    Higginson, I.J., & Hearn, J. (1997). A multicenter evaluation of pain control by palliative care teams. Journal of Pain and Symptom Management, 14, 29-35.

    Hirshkowitz, M., Moore, C.A., Hamilton, C.R.I., Rando, K.C., & Karacan, I. (1992). Polysomnography of adults and elderly: Sleep architecture, respiration, and leg movement. Journal of Clinical Neurophysiology, 9(1), 56-62.

    Hoch, C.C., Dew, M.A., Reynolds, C.F.I., Monk, T.H., Buysse, D.J., Houck, P.R., et al. (1994). A longitudinal study of laboratory- and diary-based sleep measures in healthy "old old" and "young old" volunteers. Sleep, 17, 489-496.

    Hoddes, E., Zarcone, V.P., Smythe, H., Phillips, R., & Dement, W.C. (1973). Quantification of sleepiness: A new approach. Psychophysiology, 10, 431-436.

    Holden, R.J., Pakula, I.S., & Mooney, P.A. (1998). An immunological model connecting the pathogenesis of stress, depression and carcinoma. Medical Hypotheses, 51, 315-320.

    Home, J.A., & Reid, A.J. (1985). Night-time sleep EEG changes following body heating in a warm bath. Electroencephalography and Clinical Neurophysiology, 60, 154-157.

    Hu, D., & Silberfarb, P.M. (1991). Management of sleep problems in cancer patients. Oncology, 5(2), 23-27.

    Jean-Louis, G., von Gizycki, H., Zizi, F., Fookson, J.E., Spielman, A., Nunes, J., et al. (1996). Determination of sleep and wakefulness with the actigraph data analysis software (ADAS). Sleep, 19, 739-743.

    Johns, M.W. (1991). A new method for measuring daytime sleepiness: The Epworth Sleepiness Scale. Sleep, 14, 540-545.

    Kay, D.C., & Samiuddin, Z. (1988). Sleep disorders associated with drug abuse and drugs of abuse. In R.L. Williams, I. Karacan, & C.A. Moore (Eds.)Sleep disorders: Diagnosis and treatment (2nd ed., pp. 315-371). New York: John Wiley and Sons.

    Klerman, E.B., Rimmer, D.W., Dijk, D., Kronauer, R.E., Rizzo, J.F., & Czeisler, C.A. (1998). Nonphotic entrainment of the human circadian pacemaker. American Journal of Physiology, 43, 991-996.

    Krauchi, K., Cajochen, C., Werth, E., & Wirz-Justice, A. (1999). Warm feet promote the rapid onset of sleep. Nature, 401(6748), 36-37.

    Krueger, J.M., & Fang, J. (2000). Host defense. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 255-265). Philadelphia: Saunders.

    Krueger, J.M., & Majde, J.A. (1994). Microbial products and cytokines in sleep and fever. Critical Reviews in Immunology, 14, 355-379.

    Krueger, J.M., Takahashi, S., Kapas, L., Bredow, S., Roky, R., Fang, J., et al. (1995). Cytokines and sleep. Advances in Neuroimmunology, 5, 171-188.

    Landis, C.A., Levine, J.D., & Robinson, C.R. (1989). Decreased slow-wave and paradoxical sleep in a rat chronic pain model. Sleep, 12, 167-177.

    Larbig, W., Gerber, W.D., Kluck, M., & Schoenenberger, G.A. (1984). Therapeutic effects of delta-sleep-inducing peptide (DSIP) in patients with chronic, pronounced pain episodes. European Neurology, 23, 372-385.

    Lenz, M.J., Landis, C.A., Rothermel, J., & Shaver, J.I. (1999). Effects of selective slow wave sleep disruption on musculoskeletal pain and fatigue in middle aged women. Journal of Rheumatology, 26, 1586-1592.

    McCall, W.V., Erwin, C.W., Edinger, J.D., Krystal, A.D., & Marsh, G.R. (1992). Ambulatory polysomnography: Technical aspects and normative values. Journal of Clinical Neurophysiology, 9(1), 68-77.

    McGinty, D., & Szymusiak, R. (1990). Keeping cool: A hypothesis about the mechanisms and functions of slow-wave sleep. Trends in Neurosciences, 13, 480-487.

    Meuser, T., Pietruck, C., Radbruch, L., Stute, P., Lehmann, K.A., & Grond, S. (2001). Symptoms during cancer pain treatment following WHO guidelines: A longitudinal follow-up study of symptom prevalence, severity and etiology. Pain, 93, 247-257.

    Meyers, C.A., & Valentine, A.D. (1995). Neurological and psychiatric adverse effects of immunological therapy. CNS Drugs, 3(1), 56-68.

    Miaskowski, C., & Lee, K.A. (1999). Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: A pilot study. Journal of Pain and Symptom Management, 17, 320-332.

    Miles, L. (1982). Sleep Questionnaire and Assessment of Wakefulness (SQAW). In C. Guilleminault (Ed.)Sleeping and waking disorders: Indications and techniques (pp. 384-413). Menlo Park, CA: Addison-Wesley.

    Mishma, K., Okawa, M., Shimizu, T., & Hishikawa, Y. (2001). Diminished melatonin secretion in the elderly caused by insufficient environmental illumination. Journal of Clinical Endocrinology and Metabolism, 86, 129-134.

    Moldofsky, H., & Scarisbrick, P. (1976). Induction of neurasthenic musculoskeletal pain syndrome by selective sleep stage deprivation. Psychosomatic Medicine, 38(1), 35-44.

    Monk, T.H., Buysse, D.J., Carrier, J., Billy, B.D., & Rose, L.R. (2001). Effects of afternoon "siesta" naps on sleep, alertness, performance, and circadian rhythms in the elderly. Sleep, 24, 680-687.

    Monk, T.H., Reynolds, C.F., Kupfer, D.J., Buysse, D., Coble, P.A., Hayes, A.J., et al. (1994). The Pittsburgh Sleep Diary. Journal of Sleep Research, 3, 111-120.

    Montplaisir, J., Nicolas, A., Godbout, R., & Walters, A.S. (2000). Restless legs syndrome and periodic limb movement disorder. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 742-752). Philadelphia: Saunders.

    Morin, C.M. (1993). Insomnia: Psychological assessment and management. New York: Guilford Press.

    Mormont, M.C., Waterhouse, J., Bleuzen, P., Giacchetti, S., Jami, A., Bogdan, A., et al. (2000). Marked 24-h rest/activity rhythms are associated with better quality of life, better response, and longer survival in patients with metastatic cancer and good performance status. Clinical Cancer Research, 6, 3038-3045.

    Mourits, M.J., DeVries, E.G., Willemse, P.H., Ten Hoor, K.A., Hollema, J., & Van der Zee, A.G. (2001). Tamoxifen treatment and gynecologic side effects: A review. Obstetrics and Gynecology, 97(5, Pt. 2), 855-866.

    Musselman, D.L., Miller, A.H., Porter, M.R., Manatunga, A., Gao, F., Penna, S., et al. (2001). Higher than normal plasma interleukin-6 concentrations in cancer patients with depression: Preliminary findings. American Journal of Psychiatry, 158, 1252-1257.

    Myers, B.L., & Badia, P. (1995). Changes in circadian rhythms and sleep quality with aging: Mechanisms and interventions. Neuroscience and Biobehavioral Reviews, 19, 553-571.

    National Sleep Foundation. (1999). National Sleep Foundation Sleep Diary. Retrieved November 15, 2002, from http://www.sleepfoundation.org/publications/sleepdiary.html

    Naylor, M.W., Penev, P.D., Orbeta, L., Janssen, I., Ortiz, R., Colecchia, E.F., et al. (2000). Daily social and physical activity increases slow-wave sleep and daytime neuropsychological performance in the elderly. Sleep, 23(1), 87-95.

    Nicholson, A.N., Bradley, C.M., & Pascoe, P. (1994). Medications: Effects on sleep and wakefulness. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (2nd ed., pp. 364-371). Philadelphia: Saunders.

    Ohayon, M.M., Zulley, J., Guilleminault, C., Smirne, S., & Priest, R.G. (2001). How age and daytime activities are related to insomnia in the general population: Consequences for older people. Journal of the American Geriatrics Society, 49, 360-366.

    Okawa, M., Mishima, K., Hishikawa, Y., Hozumi, S., Hori, H., & Takahashi, K. (1991). Circadian rhythm disorders in sleep-waking and body temperature in elderly patients with dementia and their treatment. Sleep, 14, 478-485.

    Oncology Nursing Society. (n.d.). Evidence-based practice resource center. Retrieved May 6, 2004, from http://onsopcontent.ons.org/toolkits/ebp/index.htm

    Parrot, A.C., & Hindmarch, I. (1980). The Leed's Sleep Evaluation Questionnaire in psychopharmacological investigations—A review. Psychopharmacology, 71, 173-179.

    Payer, J., Huorka, M., Duris, I., Ondrejka, P., Kratochvilova, H., Ilkova, M., et al. (1997). Circadian rhythmicity of plasma somatostatin, gastrin and cortisol in colon cancer patients. Hepatogastroenterology, 44, 72-77.

    Phillis, J.W., & Wu, P.H. (1982). The effect of various centrally acting drugs on adenosine uptake by the central nervous system. Comparative Biochemistry and Physiology. C: Comparative Pharmacology, 72, 179-187.

    Pilcher, J.J., & Huffcutt, A.I. (1996). Effects of sleep deprivation on performance: A meta-analysis. Sleep, 19, 318-326.

    Pollack, C.P., Tryon, W.W., Nagaraja, H., & Dzwonczyk, R. (2001). How accurately does wrist actigraphy identify the states of sleep and wakefulness? Sleep, 24, 957-965.

    Polo-Kantola, P., Erkkola, R., Helenius, H., Irjala, K., & Polo, O. (1998). When does estrogen replacement therapy improve sleep quality? American Journal of Obstetrics and Gynecology, 178, 1002-1009.

    Portenoy, R.K., Miransky, J., Thaler, H.T., Hornung, J., Bianchi, C., Cibas-Kong, I., et al. (1991). Pain in ambulatory patients with lung or colon cancer. Cancer, 70, 1616-1624.

    Redecker, N.S., Lev, E.L., & Ruggiero, J. (2000). Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy. Scholarly Inquiry for Nursing Practice, 14, 275-290.

    Rediehs, M.H., Reis, J.S., & Creason, N.S. (1990). Sleep in old age: Focus on gender differences. Sleep, 13, 410-424.

    Reichenberg, A., Yirmiya, R., Schuld, A., Kraus, T., Haack, M., Morag, A., et al. (2001). Cytokine-associated emotional and cognitive disturbances in humans. Archives of General Psychiatry, 58, 445-452.

    Reynolds, C.F.I., Shaw, D.H., Newton, T.F., Coble, P.A., & Kupfer, D.J. (1983). EEG sleep in outpatients with generalized anxiety: A preliminary comparison with depressed outpatients. Psychiatry Research, 8, 81-89.

    Ripamonti, C., Zecca, E., Brunelli, C., Groff, L., Boffi, R., Caraceni, A., et al. (2000). Pain experienced by patients hospitalized at the National Cancer Institute of Milan: Research project "towards a pain-free hospital." Tumori, 86, 412-418.

    Roehrs, T., Carskadon, M.A., Dement, W.C., & Roth, T. (2000). Daytime sleepiness and alertness. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 43-52). Philadelphia: Saunders.

    Roehrs, T., Zorick, F.J., & Roth, T. (2000). Transient and short-term insomnias. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 624-632). Philadelphia: Saunders.

    Rosen, R., & Zozula, R. (2000). Education and training in the field of sleep medicine. Current Opinion in Pulmonary Medicine, 6, 512-518.

    Rothwell, N.J. (1993). Cytokines and thermogenesis. International Journal of Obesity and Related Metabolic Disorders, 17(Suppl. 3), S98-S101.

    Sadeh, A., Hauri, P.J., Kripke, D.F., & Lavie, P. (1995). The role of actigraphy in the evaluation of sleep disorders. Sleep, 18, 288-302.

    Savard, J., & Morin, C.M. (2001). Insomnia in the context of cancer: A review of a neglected problem. Journal of Clinical Oncology, 19, 895-908.

    Schultz, H., & Lund, R. (1983). Sleep onset REM episodes are associated with circadian parameters of body temperature: A study in depressed patients and normal controls. Biological Psychiatry, 18, 1411-1426.

    Schweitzer, P.K. (2000). Drugs that disturb sleep and wakefulness. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 441-461). Philadelphia: Saunders.

    Sephton, S.E., Sapolsky, H., & Kraemer, D.S. (2000). Diurnal cortisol rhythm as a predictor of breast cancer survival. Journal of the National Cancer Institute, 92, 994-999.

    Shaver, J.L., & Giblin, E.C. (1989). Sleep. Annual Review of Nursing Research, 7, 71-73.

    Shocat, T., Luboshitzky, R., & Lavie, P. (1997). Nocturnal melatonin onset is phase locked to the primary sleep gate. American Journal of Physiology, 42(1, Pt. 2), R364-R370.

    Soldatos, C.R., Kales, A., Scharf, M.B., Bixler, E.O., & Kales, A. (1980). Cigarette smoking associated with sleep difficulty. Science, 207, 551-553.

    Spath-Schwalbe, E., Gofferje, M., Kern, W., Born, J., & Fehm, H.L. (1991). Sleep disruption alters nocturnal ACTH and cortisol secretory patterns. Biological Psychiatry, 29, 575-584.

    Spielman, A.J., & Glovinsky, P.B. (1997). The diagnostic interview and differential diagnosis for complaints of insomnis. In M.R. Pressman & W.C. Orr (Eds.)Understanding sleep: The evaluation and treatment of sleep disorders (pp. 125-160). Washington, DC: American Psychological Association.

    Spielman, A.J., Yang, C., & Glovinsky, P.B. (2000). Assessment techniques for insomnia. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 1239-1250). Philadelphia: Saunders.

    Stein, K.D., Jacobsen, P.B., Hann, D.M., Greenberg, H., & Lyman, G.H. (2000). Impact of hot flashes on quality of life among postmenopausal women being treated for breast cancer. Journal of Pain and Symptom Management, 19, 436-445.

    Strang, P. (1992). Emotional and social aspects of cancer pain. Acta Oncologica, 31, 323-326.

    Strang, P., & Qvarner, H. (1990). Cancer-related pain and its influence on quality of life. Anticancer Research, 10, 109-112.

    Tamburini, M., Selmi, S., DeConno, F., & Ventafridda, V. (1987). Semantic descriptors of pain. Pain, 25, 187-193.

    Ton, D., Zorick, F.J., Roehrs, T.A., Wittig, R.M., Sicklesteel, J.M., & Roth, T. (1988). Sleep-wake complaints and their relation to sleep disturbance. Henry Ford Hospital Medical Journal, 36(1), 9-12.

    Totterdell, P., Reynolds, S., Parkinson, B., & Briner, R.B. (1994). Associations of sleep with everyday mood, minor symptoms and social interaction experience. Sleep, 17, 466-475.

    Touitou, Y., Bogdan, A., Benavides, M., & Auzeby, A. (1996). Disruption of the circadian patterns of serum cortisol in breast and ovarian cancer patients: Relationships with tumour marker antigens. British Journal of Cancer, 74, 1248-1252.

    Touitou, Y., Levi, F., Bogdan, A., Benavides, M., Bailleul, F., & Misset, J.L. (1995). Rhythm alteration in patients with metastatic breast cancer and poor prognostic factors. Journal of Cancer Research and Clinical Oncology, 121, 181-188.

    Vainio, A., & Auvinen, A. (1996). Prevalence of symptoms among patients with advanced cancer: An international collaborative study. Symptom Prevalence Group. Journal of Pain and Symptom Management, 12, 3-10.

    Valentine, A.D., Meyers, C.A., Kling, M.A., Richelson, E., & Hauser, P. (1998). Mood and cognitive side effects of interferon-alpha therapy. Seminars in Oncology, 25(Suppl. 1), 39-47.

    Van Cauter, E. (2000). Endocrine physiology. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 266-278). Philadelphia: Saunders.

    Van Someren, E.J.W. (2000). More than a marker: Interaction between the circadian regulation of temperature and sleep, age-related changes, and treatment possibilities. Chronobiology International, 17, 313-354.

    van't Spijker, A., Trijsburg, R.W., & Duivenvoorden, H.J. (1997). Psychological sequelae of cancer diagnosis: A meta-analytical review of 58 studies after 1980. Psychosomatic Medicine, 59, 280-293.

    Weaver, T.E., Laizner, A.M., Evans, L.K., Maislin, G., Chugh, D.K., Lyon, K., et al. (1997). An instrument to measure functional status outcomes for disorders of excessive sleepiness. Sleep, 20, 835-843.

    Williams, R.L., Karacan, I., & Hursch, C.J. (1974). EEG of human sleep: Clinical applications. New York: John Wiley and Sons.

    Zarcone, V.P. (2000). Sleep hygiene. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 657-661). Philadelphia: Saunders.

    Zepelin, H. (2000). Mammalian sleep. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 82-92). Philadelphia: Saunders.

    Zorick, F.J., & Walsh, J.K. (2000). Evaluation and management of insomnia: An overview. In M.H. Kryger, T. Roth, & W.C. Dement (Eds.)Principles and practice of sleep medicine (3rd ed., pp. 615-623). Philadelphia: Saunders.

    Ellis, B.W., Johns, M.W., Lancaster, R., Raptopoulos, P., Angelopoulos, N., & Priest, R.G. (1981). The St. Mary's Hospital Sleep Questionnaire: A study of reliability. Sleep, 4, 93-97.

    Empson, J.A., & Purdie, D.W. (1999). Effects of sex steroids on sleep. Annals of Medicine, 31, 141-145.