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ORIGINAL ARTICLE
Year : 2020  |  Volume : 16  |  Issue : 6  |  Page : 1274-1278

Evaluation of sleep disorders in nonmetastatic breast cancer patients based on pittsburgh sleep quality index


Department of Medical Oncology, Bakirköy Sadi Konuk Training and Research Hospital, Istanbul, Turkey

Date of Submission26-Nov-2019
Date of Decision23-May-2020
Date of Acceptance04-Sep-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Mesut Yilmaz
Department of Medical Oncology, Bakirkoy Sadi Konuk Training and Research Hospital, Bakirkoy, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1036_19

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 > Abstract 


Background: The prevalence of breast cancer, the most common cancer in women, has remained steady over the past decades. In general, patients with early stage breast cancer undergo primary surgery with or without chemotherapy and radiotherapy. Insomnia is a very common problem in breast cancer patients, but its evaluation and treatment have not taken its place in the daily clinical application routines. In this study, we aimed to investigate the prevalence of the sleep disorders in women whose adjuvant chemotherapy and/or radiotherapy were completed at least 1 year ago and we used The Pittsburgh Sleep Quality Index (PSQI) as the standard self-report instrument in sleep disorder evaluation.
Patients and Methods: The participants were outpatients followed-up at Bakirköy Dr. Sadi Konuk Training and Research Hospital, Medical Oncology Clinic whose breast surgery performed and adjuvant chemotherapy and/or radiotherapy were completed at least one year ago, and all having histopathologically proven verified cancer diagnoses. Ninety-two participants were enrolled to study and the Pittsburgh Sleep Quality Index was used for sleep disorder evaluation.
Results: Poor quality sleep, estimated by the score of the PSQI, was observed in 53 (60%) of the participants (global score was =5). No statistically significant difference was observed between the sleep quality scores of patient groups based on endocrine treatment, manopausal status, marital status, educational status, breast surgery type, or duration after diagnoses (P > 0.05).
Conclusions: We can conclude that poor sleep quality is a highly prevalent problem in nonmetastatic breast cancer patients, we determined a high prevalence rate of insomnia at 60%. PSQI is an appropriate and useful tool that physicians can apply while assessing sleep disorders in cancer patients. The improvement in the diagnosis and management of sleep disorders will contribute to a major improvement in the symptom control of insomnia for cancer patients.

Keywords: Breast cancer, insomnia, Pittsburgh Sleep Quality Index, sleep disorders


How to cite this article:
Yilmaz M. Evaluation of sleep disorders in nonmetastatic breast cancer patients based on pittsburgh sleep quality index. J Can Res Ther 2020;16:1274-8

How to cite this URL:
Yilmaz M. Evaluation of sleep disorders in nonmetastatic breast cancer patients based on pittsburgh sleep quality index. J Can Res Ther [serial online] 2020 [cited 2021 Dec 4];16:1274-8. Available from: https://www.cancerjournal.net/text.asp?2020/16/6/1274/303883




 > Introduction Top


The prevalence of breast cancer, the most common cancer in women, has remained steady over the past decade; death from breast cancer has consistently decreased periodically since approximately 1990, primarily as a result of advancements in systemic therapy.[1] The most common breast cancer subtype is hormone receptor-positive (HR+) disease, which composes 75% of all breast cancers.[2] In general, patients with early-stage breast cancer undergo primary surgery with or without radiation therapy. Following local treatment, adjuvant systemic therapy may be offered based on primary tumor features, such as tumor size, grade, lymph node involvement, HR status and expression of human epidermal growth factor 2 (HER2) receptor.[3] However, some patients with early-stage breast cancer (especially those with HER2-positive or triple-negative disease) may be treated with neoadjuvant chemotherapy first, followed by the surgery. Patients with invasive breast cancers that are HR+ should be considered for adjuvant endocrine therapy regardless of patient age, lymph node status, or whether adjuvant chemotherapy are to be administered.[4] An aromatase inhibitor (AI) is the preferred adjuvant treatment of postmenopausal women, although tamoxifen is an acceptable alternative for women who are intolerant of AIs. Tamoxifen with or without the addition of ovarian function suppression (OFS) and exemestane with OFS is recommended for adjuvant therapy in premenopausal patients.[5]

There is an increasing recognition that psychological issues are the main concerns for cancer survivors posttreatment, although the magnitude of difference between survivors and healthy controls is not clear.[6] Among the factors which negatively affect their quality of life, patients with cancer experience the presence of depression, anxiety, fear of recurrence, posttraumatic-stress, sexual dysfunction, fatigue, pain, and sleep disturbances – it being the case that these can also contribute to an increase in mortality.[7],[8]

According to the International Classification of Sleep Disorders, Third Edition, insomnia is present if the patient reports; difficulty initiating sleep, difficulty maintaining sleep, or waking up too early, despite adequate opportunity and circumstances for sleep, and daytime impairment that is attributable to the sleep difficulties.[9]

Poor sleep quality is an significant contributor to low health-related quality of life and is estimated to affect up to 70% of breast cancer patients,[10] depending on the method of sleep evaluation and study design used. Cancer treatment has been associated with the existence of sleep disturbances among women with breast cancer. Women submitted to chemotherapy, as well as radiotherapy, tended to describe the higher levels of sleep disorders; inconsistent findings were seen regarding the various options for surgery and the use of hormonal therapy.[11] The high prevalence of poor quality sleep is concerning, as it is generally observed in association with worsening of health, affecting the regulation of the immunological functions, and also it may cause changes in cognition and memory, emotional imbalance, and increase in appetite.[12] The management of poor quality sleep is essential in these women and should be preceded by the description of the factors associated with it, at different points of the diagnosis and treatment.

Insomnia is a very common problem in breast cancer patients, but its evaluation and treatment have not taken its place in the daily clinical application routines. There are several subjective sleep evaluation methods, and only a few can be used to assess sleep quality and disorders in cancer patients.[13] The Pittsburgh Sleep Quality Index (PSQI) is a self-administered questionnaire to evaluate sleep quality, commonly used in the general population and populations with different clinical diagnoses including breast cancer patients.[14] Agargün et al. conducted validity and reliability studies of this index in Turkey, and many studies were done using the Turkish version of PSQI.[15]

In this study, we aimed to investigate the prevalence of the sleep disorders and its associations with patient demographics, clinical characteristics, and endocrine therapy options in women whose adjuvant chemotherapy and/or radiotherapy were completed at least 1 year ago and we used PSQI as the standard self-report instrument in sleep disorder evaluation.


 > Patients and Methods Top


This study was conducted at the Division of Medical Oncology of the Department of Internal Medicine, Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. The hospital's local ethical committee approval was obtained before the initiation of the study. The participants were outpatients followed-up at our center whose breast surgery performed and adjuvant chemotherapy and/or radiotherapy were completed at least 1 year ago, and all having histopathologically proven verified cancer diagnoses. An informed consent form was obtained from all patients. Sociodemographic and clinical information was gathered for each patient from their admission documents. The study had the following inclusion criteria: Women aged 18 years old or over, with a diagnosis of breast cancer, stages I-III, who were completed adjuvant chemotherapy and/or radiotherapy at least 1 year ago. The exclusion criteria consisted of significant psychiatric or noncancer medical illness that may cause sleep disorders such as chronic heart failure and chronic obstructive pulmonary disease, concurrent use of medications known to affect sleep, and night-shift employment.

PSQI is the most commonly used subjective test of sleep dysfunction in clinical and nonclinical subjects.[16] We have concluded that PSQI is an appropriate and useful tool to administer while studying sleep disorders in cancer patients. The questions were asked in an uncomplicated and clear manner and were understood easily by all patients independent of their level of education. In addition, it did not require a high level of training for the clinicians and researchers to administer the instrument. In our study, the patients completed the validated Turkish version of PSQI during the routine outpatient follow-up visit. PSQI is a 19-item self-report questionnaire assessing sleep quality and sleep disorders for more than 1 month. It results in a total global score from 0 to 21 and contains of seven domains: (1) subjective sleep quality (1 question), (2) sleep latency (2 questions), (3) sleep duration (1 question), (4) normal sleep efficiency (3 questions), (5) sleep disturbances (9 questions), (6) the application of sleep medicine (1 question), and (7) daytime dysfunction (2 questions). Each item has a response scale score ranging from 0 to 3, and the lower score indicates better sleep quality. Moreover, a PSQI total score of 5 or more has great sensitivity and specificity for identifying people with sleep impairment or not.[17]

Statistical analyses were performed using the SPSS 22.0 software (SPSS Inc., Chicago, IL, USA). All parameters were reported with descriptive statistics. T-test and Mann–Whitney U-test were used in the comparison of continuous parameters of groups based on good/bad sleep quality and endocrine treatment, menopausal status, marital status, educational status, breast surgery type, or duration after diagnoses. Categorical parameters were compared through χ2 test. Spearman's correlation was used to evaluate the associations between sleep quality and other parameters. Statistical significance level was set at P < 0.05.


 > Results Top


Between January 2019 and July 2019, breast cancer patients who attended the follow-up visit were assessed for the study. One hundred and four patients were eligible, but 12 patients were not accepted to participate in the study due to the lack of interest. Hence, final enrolment consisted of 92 participants and patient demographics and clinical characteristics are presented in [Table 1]. The mean age of participants was 54.9 (range: 33–78 years). The majority of patients were married (75.0%). More than half of patients were primary school graduates and only 11% of participants had university diploma. Breast conservative surgery was performed to 65% of these patients, and the others had mastectomy. Eighty-five percent of participants were treated with chemotherapy and only seven patients had neoadjuvant chemotherapy. Forty-six patients were treating with AI and 35 patients with tamoxifen.
Table 1: Demographic and clinical characteristics of the patients

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Poor quality sleep, estimated by the score of the PSQI, was observed in 53 (60%) of the participants (global score was = 5). No statistically significant difference was observed between the sleep quality scores of patient groups based on endocrine treatment, menopausal status, marital status, educational status, breast surgery type, or duration after diagnoses (P > 0.05) [Table 2].
Table 2: No statistically significant difference was observed between the sleep quality scores of patient groups based on endocrine treatment, menopausal status, marital status, educational status, breast surgery type, or duration after diagnoses (P > 0.05)

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 > Discussion Top


The primary goal of this study was to evaluate the sleep quality based on the PSQI in women who had been operated and adjuvant chemotherapy and/or radiotherapy were completed for nonmetastatic breast cancer. More than half (60%) of the sample reported sleep disorders, and this is consistent with the prior data collected in breast cancer patients.[18]

Sleep is crucial to the maintenance of physiological and psychological health in humans. Sleep disorders are known to impact the quality of life and psychological well-being of cancer patients as well. Moreover, sleep disturbance is a notable problem in patients with cancer, especially breast cancer, head and neck cancer, lung cancer, and gynecologic cancer.[19] The incidence rate of sleep disorders in cancer patients was 30% to 93.1%, which is higher than 9% to 33% in the general population, depending on the method of sleep evaluation and study design used.[20] Waking up frequently during the night for patients with cancer is the most common sleep disorder. Cancer itself and cancer treatments were the probable factors contributing to sleep disorder and also simultaneous symptoms such as fatigue, distress, and pain increase the level of sleep disturbance. Sleep disorders can be evaluated objectively with methods such as polysomnography, bispectral index, and actigraphy and subjectively with sleep diaries and methods involving self-report instruments such as PSQI, Insomnia Severity Index, and Epworth Sleepiness Scale.[21]

Sixty percent of nonmetastatic breast cancer patients had bad sleep quality in this study. The prior researchers described that insomnia prevalence varies between 39.5 and 69% and that this rate is higher among breast cancer patients compared with the general healthy population.[22] There are numerous complex etiological factors affecting sleep disorders in cancer patients. While demographic characteristics such as age, gender, personality, habits, perpetual maladaptive sleep behaviors, and their own and familial history are important factors among those precipitating insomnia in cancer patients, predisposing factors such different sleep measurement methods, different assessing time points, and different treatments for breast cancer, such as surgery, radiation therapy, chemotherapy, or therapeutic alliance.[19]

Ancoli-Israel et al. found that worsened sleep and more disrupted circadian activity rhythms occurred after the four cycles of chemotherapy in nonmetastatic breast cancer patients.[23] Moreover, also they showed 1 year after of completion of chemotherapy sleep disorders returned to baseline levels, but were still worse than controls. However, in another study, Ratcliff and co-workers found that sleep quality and sleep fragmentation remained stable during the chemotherapy, sleep efficiency increased, and sleep latency decreased over time.[24] In our study, we found a similar frequency of sleep disturbances in patients whose definitive treatment (surgery, chemotherapy, and radiotherapy) for breast cancer was completed within 3 years and longer.

Savard et al. indicated that lumpectomy was associated with an increased risk to report insomnia symptoms was unexpected and is rather attractive considering that lumpectomy is a less disfiguring and presumably less distressing surgical procedure.[18] It has been suggested that women who undergo lumpectomy are more distressed because of the fearful thought that cancer cells could have been left in their breasts. In contrast to this study, we did not find any difference between the incidence of sleep disorders among patients who underwent mastectomy and lumpectomy for breast cancer treatment.

The relationship between the frequency of sleep disorder and education level in women receiving adjuvant chemotherapy for breast cancer was investigated, but no relationship was found.[23] In another study conducted in a similar group of patients treated with adjuvant radiotherapy, they indicated women with a university degree had an increased risk to suffer from an insomnia syndrome.[18] In our study, no correlation was found between education level and sleep quality in nonmetastatic breast cancer patients. And also, we found no relationship between tamoxifen or AI therapy and sleep disorders incidence in HR+ patients.

Although sleep disorders a very common problem in cancer patients, this is often not properly evaluated and treated in daily clinical practice.[18],[22] One of the most important issues is the inadequate evaluation of the patients. There are a few questionnaires that can be used in the daily clinical application routines for this purpose. In this study, we used the PSQI test to evaluate sleep quality and to detect sleep disturbance because it is both a reliable method and easy to apply in the daily practice.[15] In our study, we found that only eight out of 53 patients with poor sleep quality were receiving medication. Considering that sleep disorders are more frequent in cancer patients than in the general population, it should be ensured that patients have access to appropriate treatment methods.

This study has some limitations. The data were only collected in a small number of women with stage I-III breast cancer, so the results cannot be extended to patients with stage IV breast cancer, with other types of cancer, or male patients with breast cancer. The patients were all drawn from a particular geographic region and one that has considerably restricted seasonal variations, a factor which might help reduce the study participants' physical and mental distress and capability to cope with a cancer diagnosis. Nevertheless, psychological disorders were not optimally assessed in this study, as patients were only asked to say whether they were having psychological troubles at the time of the interview. To explore more approximately the influence of psychological morbidity, future research should assess psychological disturbances (e.g., anxiety and depression) with a structured diagnostic interview or at least with well-validated psychometric instruments.

In spite of these limitations, we can conclude that poor sleep quality is a highly prevalent problem in nonmetastatic breast cancer patients, we determined a high prevalence rate of insomnia at 60%. PSQI is an appropriate and useful tool that physicians can apply while assessing sleep disorders in cancer patients. With a better understanding of the nature and prevalence of sleep problems among cancer patients, new approaches in supportive care and new guidelines for the evaluation and management of cancer-related insomnia can be formed. The improvement in the diagnosis and management of sleep disorders will contribute to a major improvement in the symptom control of insomnia for cancer patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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