Cognitive Behavioral Therapy for Insomnia Outcomes in Women After Primary Breast Cancer Treatment: A Randomized, Controlled Trial

Ellyn E. Matthews

Ann M. Berger

Sarah J. Schmiege

Paul F. Cook

Michaela S. McCarthy

Camille M. Moore

Mark S. Aloia

breast cancer, fatigue, outcomes research, survivorship, late effects of cancer treatment
ONF 2014, 41(3), 241-253. DOI: 10.1188/14.ONF.41-03AP

Purpose/Objectives: To examine the effect of cognitive-behavioral therapy for insomnia (CBTI) on sleep improvement, daytime symptoms, and quality of life (QOL) in breast cancer survivors (BCSs) after cancer treatment.

Design: A prospective, longitudinal, randomized, controlled trial.

Setting: Oncology clinics, breast cancer support groups, and communities in Colorado.

Sample: 56 middle-aged BCSs with chronic insomnia.

Methods: Women were randomly assigned to CBTI or behavioral placebo treatment (BPT) and completed measures of sleep, QOL, functioning, fatigue, and mood at baseline, postintervention, and at three- and six-month follow-ups.

Main Research Variables: Sleep outcomes (e.g., sleep efficiency, sleep latency, total sleep time, wake after sleep onset, number of nightly awakenings); secondary variables included sleep medication use, insomnia severity, QOL, physical function, cognitive function, fatigue, depression, anxiety, and sleep attitudes or knowledge.

Findings: Sleep efficiency and latency improved more in the CBTI group than the BPT group; this difference was maintained during follow-up. Women in the CBTI group had less subjective insomnia, greater improvements in physical and cognitive functioning, positive sleep attitudes, and increased sleep hygiene knowledge. No group differences in improvement were noted relative to QOL, fatigue, or mood.

Conclusions: Nurse-delivered CBTI appears to be beneficial for BCSs' sleep latency/efficiency, insomnia severity, functioning, sleep knowledge, and attitudes more than active placebo, with sustained benefit over time.

Implications for Nursing: Oncology nurses are in a unique position to identify insomnia in cancer survivors. When sleep disturbances become chronic, nurses need to make recommendations and referrals.

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    Ahn, S.H., Park, B.W., Noh, D.Y., Nam, S.J., Lee, E.S., Lee, M.K., … Yun, Y.H. (2006). Health-related quality of life in disease-free survivors of breast cancer with the general population. Annals of Oncology, 18, 173-182. doi:10.1093/annonc/mdl333
    Ancoli-Israel, S., Liu, L., Marler, M.R., Parker, B.A., Jones, V., Sadler, G.R., … Fiorentino, L. (2006). Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Supportive Care in Cancer, 14, 201-209. doi:10.1007/s00520-005-0861-0
    Appling, S.E., Scarvalone, S., MacDonald, R., McBeth, M., & Helzlsouer, K.J. (2012). Fatigue in breast cancer survivors: The impact of a mind-body medicine intervention. Oncology Nursing Forum, 39, 278-286. doi:10.1188/12.ONF.278-286
    Arndt, V., Merx, H., Stegmaier, C., Ziegler, H., & Brenner, H. (2005). Persistence of restrictions in quality of life from the first to the third year after diagnosis in women with breast cancer. Journal of Clinical Oncology, 23, 4945-4953. doi:10.1200/JCO.2005.03.475
    Arnedt, J.T., Conroy, D.A., Armitage, R., & Brower, K.J. (2011). Cognitive-behavioral therapy for insomnia in alcohol dependent patients: A randomized controlled pilot trial. Behavior Research and Therapy, 49, 227-233. doi:10.1016/j.brat.2011.02.003
    Bastien, C.H., Vallieres, A., & Morin, C.M. (2001). Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Medicine, 2, 297-307. doi:10.1016/S1389-9457 (00)00065-4
    Berger, A.M. (2009). Update on the state of the science: Sleep-wake disturbances in adult patients with cancer [Online exclusive]. Oncology Nursing Forum, 36, E165-E177. doi:10.1188/09.ONF.E165-E177
    Berger, A.M., Kuhn, B.R., Farr, L.A., Lynch, J.C., Agrawal, S., Chamberlain, J., & Von Essen, S.G. (2009). Behavioral therapy intervention trial to improve sleep quality and cancer-related fatigue. Psycho-Oncology, 18, 634-646. doi:10.1002/pon.1438
    Berger, A.M., Kuhn, B.R., Farr, L.A., Von Essen, S.G., Chamberlain, J., Lynch, J.C., & Agrawal, S. (2009). One-year outcomes of a behavioral therapy intervention trial on sleep quality and cancer-related fatigue. Journal of Clinical Oncology, 27, 6033-6040. doi:10.1200/JCO.2008.20.8306
    Berger, A.M., Von Essen, S., Khun, B.R., Piper, B.F., Farr, L., Agrawal, S., … Higginbothom, P. (2002). Feasibilty of a sleep intervention during adjuvant breast cancer chemotherapy. Oncology Nursing Forum, 29, 1431-1441. doi:10.1188/02.ONF.1431-1441
    Blask, D.E., Hill, S.M., Dauchy, R.T., Xiang, S., Yuan, L., Duplessis, T., … Sauer, L.A. (2011). Circadian regulation of molecular, dietary, and metabolic signaling mechanisms of human breast cancer growth by the nocturnal melatonin signal and the consequences of its disruption by light at night. Journal of Pineal Research, 51, 259-269. doi:10.1111/j.1600-079X.2011.00888.x
    Bootzin, R.R., & Perlis, M.L. (1992). Nonpharmacologic treatments of insomnia. Journal of Clinical Psychiatry, 53(Suppl.), 37-41.
    Bray, F., Ren, J.S., Masuyer, E., & Ferlay, J. (2013). Global estimates of cancer prevalence for 27 sites in the adult population in 2008. International Journal of Cancer, 132, 1133-1145. doi:10.1002/ijc.27711
    Buysse, D.J. (2013). Insomnia. JAMA, 309, 706-716.
    Caplette-Gingras, A., Savard, J., Savard, M.H., & Ivers, H. (2012). Is insomnia associated with cognitive impairments in breast cancer patients? Behavioral Sleep Medicine, 11, 239-257. doi:10.1080/15402002.2012.672940
    Carney, C.E., Edinger, J.D., Morin, C.M., Manber, R., Rybarczyk, B., Stepanski, E.J., & Lack, L. (2010). Examining maladaptive beliefs about sleep across insomnia patient groups. Journal of Psychosomatic Research, 68, 57-65. doi:10.1016/j.jpsychores.2009.08.007
    Chen, M.L., Miaskowski, C., Liu, L.N., & Chen, S.C. (2012). Changes in perceived attentional function in women following breast cancer surgery. Breast Cancer Research and Treatment, 131, 599-606. doi:10.1007/s10549-011-1760-3
    Cimprich, B. (1993). Development of an intervention to restore attention in cancer patients. Cancer Nursing, 16, 83-92.
    Cimprich, B. (1999). Pretreatment symptom distress in women newly diagnosed with breast cancer. Cancer Nursing, 22, 185-195.
    Coates, T.J., Killen, J.D., George, J., Marchini, E., Silverman, S., & Thoresen, C. (1982). Estimating sleep parameters: A multitrait-multimethod analysis. Journal of Consulting and Clinical Psychology, 50, 345-352. doi:10.1037/0022-006X.50.3.345
    Cohen, M., & Fried, G. (2007). Comparing relaxation training and cognitive-behavioral group therapy for women with breast cancer. Research on Social Work Practice, 17, 313-323.
    de Jong, N., Candel, M.J., Schouten, H.C., bu-Saad, H.H., & Courtens, A.M. (2006). Course of the fatigue dimension "activity level" and the interference of fatigue with daily living activities for patients with breast cancer receiving adjuvant chemotherapy. Cancer Nursing, 29, E1-E13.
    Desai, K., Mao, J.J., Su, I., Demichele, A., Li, Q., Xie, S.X., & Gehrman, P.R. (2013). Prevalence and risk factors for insomnia among breast cancer patients on aromatase inhibitors. Supportive Care in Cancer, 21, 43-51. doi:10.1007/s00520-012-1490-z
    Dirksen, S.R., Belyea, M.J., & Epstein, D.R. (2009). Fatigue-based subgroups of breast cancer survivors with insomnia. Cancer Nursing, 32, 404-411. doi:10.1097/NCC.0b013e3181a5d05e
    Dirksen, S.R., & Epstein, D.R. (2008). Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. Journal of Advanced Nursing, 61, 664-675.
    Edinger, J., & Carney, C. (2008). Overcoming insomnia: A cognitive-behavioral therapy approach therapist guide. New York, NY: Oxford University Press.
    Edinger, J.D., Wohlgemuth, W.K., Radtke, R.A., Marsh, G.R., & Quillian, R.E. (2001a). Cognitive behavioral therapy for treatment of chronic primary insomnia: A randomized controlled trial. JAMA, 285, 1856-1864. doi:10.1001/jama.285.14.1856
    Edinger, J.D., Wohlgemuth, W.K., Radtke, R.A., Marsh, G.R., & Quillian, R.E. (2001b). Does cognitive-behavioral insomnia therapy alter dysfunctional beliefs about sleep? Sleep, 24, 591-599.
    Epstein, D.R., & Dirksen, S.R. (2007). Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors [Online exclusive]. Oncology Nursing Forum, 34, E51-E59. doi:10.1188/07.ONF.E51-E59
    Espie, C.A. (2009). "Stepped care": A health technology solution for delivering cognitive behavioral therapy as a first line insomnia treatment. Sleep, 32, 1549-1558.
    Espie, C.A., Fleming, L., Cassidy, J., Samuel, L., Taylor, L.M., White, C.A., … Paul, J. (2008). Randomized controlled clinical effectiveness trial of cognitive behavior therapy compared with treatment as usual for persistent insomnia in patients with cancer. Journal of Clinical Oncology, 26, 4651-4658. doi:10.1200/JCO.2007.13.9006
    Espie, C.A., Inglis, S.J., Tessier, S., & Harvey, L. (2001). The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: Implementation and evaluation of a sleep clinic in general medical practice. Behavior Research and Therapy, 39, 45-60. doi:10.1016/S0005-7967(99)00157-6
    Fayers, P.M., Aaronson, N.K., Bjordal, K., Groenvold, M., Curran, D., & Bottomley, A. (2001). The EORTC QLQ-C30 scoring manual (3rd ed.). Brussels, Belgium: European Organisation for the Research and Treatment of Cancer.
    Filipski, E., King, V.M., Li, X., Granda, T.G., Mormont, M.C., Claustrat, B., … Levi, F. (2003). Disruption of circadian coordination accelerates malignant growth in mice. Patholgie Biologie, 51, 216-219. doi:10.1016/S0369-8114(03)00034-8
    Filipski, E., King, V.M., Li, X., Granda, T.G., Mormont, M.C., Liu, X., … Levi, F. (2002). Host circadian clock as a control point in tumor progression. Journal of the National Cancer Institute, 94, 690-697. doi:10.1093/jnci/94.9.690
    Fiorentino, L., & Ancoli-Israel, S. (2006). Insomnia and its treatment in women with breast cancer. Sleep Medicine Reviews, 10, 419-429. doi:10.1016/j.smrv.2006.03.005
    Fortner, B.V., Stepanski, E.J., Wang, S.C., Kasprowicz, S., & Durrence, H.H. (2002). Sleep and quality of life in breast cancer patients. Journal of Pain and Symptom Management, 24, 471-480. doi:10.1016/S0885-3924(02)00500-6
    Innominato, P.F., Focan, C., Gorlia, T., Moreau, T., Garufi, C., Waterhouse, J., … Bjarnason, B.J. (2009). Circadian rhythm in rest and activity: A biological correlate of quality of life and a predictor of survival in patients with metastatic colorectal cancer. Cancer Research, 69, 4700-4707. doi:10.1158/0008-5472.CAN-08-4747
    Kluthcovsky, A.C., Urbanetz A.A., de Carvalho, D.S., Pereira Maluf, E.M., Schlickmann Sylvestre, G.C., & Bonatto Hatschbach, S.B. (2012). Fatigue after treatment in breast cancer survivors: prevalence, determinants and impact on health-related quality of life. Supportive Care in Cancer, 20, 1901-1909.
    Manber, R., Edinger, J.D., Gress, J.L., San Pedro-Salcedo, M.G., Kuo, T.F., & Kalista, T. (2008). Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep, 31, 489-495.
    Matthews, E.E., Cook, P.F., Terada, M., & Aloia, M.S. (2010). Randomizing research participants: Promoting balance and concealment in small samples. Research in Nursing and Health, 33, 243-253.
    Matthews, E.E., Schmiege, S.J., Cook, P.F., Berger, A.M., & Aloia, M.S. (2012). Adherence to cognitive behavioral therapy for insomnia (CBTI) among women following primary breast cancer treatment: A pilot study. Behavioral Sleep Medicine, 10, 1-13. doi:10.1080/15402002.2012.666220
    Minton, O., Alexander, S., & Stone, P.C. (2012). Identification of factors associated with cancer related fatigue syndrome in disease-free breast cancer patients after completing primary treatment. Breast Cancer Research and Treatment, 136, 513-520.
    Minton, O., & Stone, P.C. (2013). A comparison of cognitive function, sleep and activity levels in disease-free breast cancer patients with or without cancer-related fatigue syndrome. BMJ Supportive and Palliative Care, 2, 231-238. doi:10.1136/bmjspcare-2011-000172
    Moore, T.A., Berger, A.M., & Dizona, P. (2011). Sleep aid use during and following breast cancer adjuvant chemotherapy. Psycho-Oncology, 20, 321-325. doi:10.1002/pon.1756
    Moorey, S., Greer, S., Watson, M., Gorman, C., Rowden, L., Tunmore, R., … Bliss, J. (1991). The factor structure and factor stability of the hospital anxiety and depression scale in patients with cancer. British Journal of Psychiatry, 158, 255-259. doi:10.1192/bjp.158.2.255
    Morin, C.M. (1993). Insomnia: Psychological assessment and management. New York, NY: Guilford Press.
    Morin, C.M., & Benca, R. (2012). Chronic insomnia. Lancet, 24, 1129-1141.
    Morin, C.M., Bootzin, R.R., Buysse, D.J., Edinger, J.D., Espie, C.A., & Lichstein, K.L. (2006). Psychological and behavioral treatment of insomnia: Update of the recent evidence (1998-2004). Sleep, 29, 1398-1414.
    Morin, C.M., Colecchi, C., Stone, J., Sood, R., & Brink, D. (1999). Behavioral and pharmacological therapies for late-life insomnia: A randomized controlled trial. JAMA, 281, 991-999. doi:10.1001/jama.281.11.991
    Morin, C.M., Vallieres, A., & Ivers, H. (2007). Dysfunctional beliefs and attitudes about sleep (DBAS): Validation of a brief version (DBAS-16). Sleep, 30, 1547-1554.
    Mormont, M.C., Waterhouse, J., Bleuzen, P., Giacchetti, S., Jami, A., Bogdan, A., & Levi, F. (2000). Marked 24-h rest/activity rhythms are associated with better quality of life, better response, and longer survival in patients with metastatic colorectal cancer and good performance status. Clinical Cancer Research, 6, 3038-3045.
    Murtagh, D.R., & Greenwood, K.M. (1995). Identifying effective psychological treatments for insomnia: A meta-analysis. Journal of Consulting and Clinical Psychology, 63, 79-89. doi:10.1037/0022-006X.63.1.79
    Nakaguchi, T., Okuyama, T., Uchida, M., Ito, Y., Komatsu, H., Wada, M., & Akechi, T. (2013). Oncology nurses' recognition of supportive care needs and symptoms of their patients undergoing chemotherapy. Japanese Journal of Clinical Oncology, 43, 369-376. doi:10.1093/jjco/hyt003
    Okuyama, T., Akechi, T., Yamashita, H., Toyama, T., Nakaguchi, T., Uchida, M., … Furukawa, T.A. (2011). Oncologists' recognition of supportive care needs and symptoms of their patients in a breast cancer outpatient consultation. Japanese Journal of Clinical Oncology, 41, 1251-1258. doi:10.1093/jjco/hyr146
    Page, M., & Berger, A. (2009). Sleep-wake disturbances. In L. Eaton & J. Tipton (Eds.), Oncology Nursing Society Putting Evidence Into Practice: Improving oncology patient outcomes (pp. 285-297). Pittsburgh, PA: Oncology Nursing Society.
    Palesh, O.G., Roscoe, J.A., Mustian, K.M., Roth, T., Savard, J., Ancoli-Israel, S., … Morrow, G.R. (2010). Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. Journal of Clinical Oncology, 28, 292-298. doi:10.1200/JCO.2009.22.5011
    Payne, J., Piper, B., Rabinowitz, I., & Zimmerman, B. (2006). Biomarkers, fatigue, sleep, and depressive symptoms in women with breast cancer: A pilot study. Oncology Nursing Forum, 33, 775-783. doi:10.1188/06.ONF.775-783
    Perlis, M.L., Jungquist, C., Smith, M.T., & Posner, D. (2005). Cognitive behavioral treatment of insomnia: A session-by-session guide. New York, NY: Springer.
    Piper, B.F., Dibble, S.L., Dodd, M.J., Weiss, M.C., Slaughter, R.E., & Paul, S.M. (1998). The revised Piper Fatigue Scale: Psychometric evaluation in women with breast cancer. Oncology Nursing Forum, 25, 677-684.
    Quesnel, C., Savard, J., Simard, S., Ivers, H., & Morin, C.M. (2003). Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastatic breast cancer. Journal of Consulting and Clinical Psychology, 71, 189-200. doi:10.1037/0022-006X.71.1.189
    Rogers, A.E., Caruso, C.C., & Aldrich, M.S. (1993). Reliability of sleep diaries for assessment of sleep/wake patterns. Nursing Research, 42, 368-372.
    Rumble, M.E., Keefe, F.J., Edinger, J.D., Porter, L.S., & Garst, J.L. (2005). A pilot study investigating the utility of the cognitive-behavioral model of insomnia in early-stage lung cancer patients. Journal of Pain and Symptom Management, 30, 160-169. doi:10.1016/j.jpainsymman.2005.02.013
    Savard, J., Ivers, H., Villa, J., Caplette-Gingras, A., & Morin, C.M. (2011). Natural course of insomnia comorbid with cancer: An 18-month longitudinal study. Journal of Clinical Oncology, 29, 3580-3586. doi:10.1200/JCO.2010.33.2247
    Savard, J., Simard, S., Blanchet, J., Ivers, H., & Morin, C.M. (2001). Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep, 24, 583-590.
    Savard, J., Simard, S., Ivers, H., & Morin, C.M. (2005). Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: Sleep and psychological effects. Journal of Clinical Oncology, 23, 6083-6096. doi:10.1200/JCO.2005.09.548
    Savard, J., Villa, J., Ivers, H., Simard, S., & Morin, C.M. (2009). Prevalence, natural course, and risk factors of insomnia comorbid with cancer over a 2-month period. Journal of Clinical Oncology, 27, 5233-5239. doi:10.1200/JCO.2008.21.6333
    Savard, M., Savard, J., Simard, S., & Ivers, H. (2005). Empirical validation of the Insomnia Severity Index in cancer patients. Psycho-Oncology, 14, 429-441. doi:10.1002/pon.860
    Schutte-Rodin, S., Broch, L., Buysse, D., Dorsey, C., & Sateia, M. (2008). Clinical guideline for the evaluation and management of chronic insomnia in adults. Journal of Clinical Sleep Medicine, 4, 487-504.
    Spielman, A.J., Saskin, P., & Thorpy, M.J. (1987). Treatment of chronic insomnia by restriction of time in bed. Sleep, 10, 45-56.
    Steinmark, S.W., & Borkovec, T.D. (1974). Active and placebo treatment effects on moderate insomnia under counterdemand and positive demand instructions. Journal of Abnormal Psychology, 83, 157-163. doi:10.1037/h0036489
    Tremblay, V., Savard, J., & Ivers, H. (2009). Predictors of the effect of cognitive behavioral therapy for chronic insomnia comorbid with breast cancer. Journal of Consulting and Clinical Psychology, 77, 742-750. doi:10.1037/a0015492
    Trudel-Fitzgerald, C., Savard, J., & Ivers, H. (2013). Evolution of cancer-related symptoms over an 18-month period. Journal of Pain and Symptom Management, 45, 1007-1018.
    U.S. Census Bureau. (2013). Table H-8. Median household income by state: 1984 to 2011. Retrieved from
    Vitiello, M.V., McCurry, S.M., & Rybarczyk, B.D. (2013). The future of cognitive behavioral therapy for insomnia: What important research remains to be done? Journal of Clinical Psychology, 69, 1013-1021. doi:10.1002/jclp.21948
    Wefel, J.S., & Schagen, S.B. (2012). Chemotherapy-related cognitive dysfunction. Current Neurological and Neuroscience Report, 12, 267-275. doi:10.1007/s11910-012-0264-9
    Yang, M., Morin, C.M., Schaefer, K., & Wallenstein, G.V. (2009). Interpreting score differences in the Insomnia Severity Index: Using health-related outcomes to define the minimally important difference. Current Medical Research and Opinion, 25, 2487-2494. doi:10.1185/03007990903167415.
    Zigmond, A.S., & Snaith, R.P. (1983). The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica, 67, 361-370. doi:10.1111/j.1600-0447.1983.tb09716.x
    Zucca, A.C., Boyes, A.W., Linden, W., & Girgis, A. (2012). All's well that ends well? Quality of life and physical symptom clusters in long-term cancer survivors across cancer types. Journal of Pain and Symptom Management, 43, 720-731.