Here, 31% of our participants had at least a moderate level of insomnia symptoms, and these participants reported more sleepiness and fatigue than those with less severe insomnia symptoms. As also found in the general population with insomnia, they also were less of a “morning” person and claimed to have more dreaming frequency. It would be interesting for further research to investigate how various prostate cancer treatment (e.g., androgen deprivation therapy) affects different stages of sleep, particularly the rapid eye movement which is often associated with dreaming. Also, we are curious to know about dream content because, in other populations, people with insomnia reported a higher frequency of nightmares.4, 5
In terms of management strategies, we asked participants if they had used six different strategies for improving their sleep and, if they had not used any of them, we asked whether they would be willing to try them. We found that patients with more severe insomnia symptoms are more likely to have used medication, cognitive behavioural therapy (CBT), as well as herbal remedies/supplements to improve their sleep. Among those who had not used the strategies, those with more severe insomnia symptoms were more open to trying CBT and hypnosis.
Of important note, using sleep medication was not endorsed by many patients, despite the fact that medication is a common first-line treatment for sleep problems in the general population. Some patients (~35% for each reason) did not want pharmacotherapy to improve their sleep due to either side effect concerns, and the concurrent use of other medications. We do not know the type and indications for their other medications, and if they were for treating their or other comorbidities. Our data suggest that clinicians should consider non-pharmacological treatment options (e.g., CBT) since their patients may not always be interested in taking additional medications.
We are intrigued that patients are generally open to trying CBT as this treatment is the recommended treatment for insomnia in cancer patients.6 Considering that CBT can be expensive, we are surprised that only 2 participants were not willing to try CBT due to cost. This may be because we did not specify what the costs would be, or because about 52% of our participants have a household income of over $60,000. In Aotearoa New Zealand, there is little research done to compare sleep intervention costs. There is a possibility that if patients were aware of the average costs of various treatments then our results might be different because these options are generally not covered by their health insurance.
Interestingly, even though hypnosis is not a common treatment for sleep, a large proportion of patients in our study were interested in trying hypnosis as a sleep management strategy. Hypnosis has not been well studied for sleep, and evidence for its efficacy remains inconsistent.7 We are unsure why such a large proportion of our sample were interested in hypnosis, and perceive that hypnosis may help them sleep better. Given this interest, future research could explore the effectiveness of hypnosis in reducing insomnia symptoms in PCa patients.
We acknowledge that our study has multiple limitations. For example, our sample size is small and the majority were Caucasian with higher education and socioeconomic background. However, this means our study may not be as generalisable to other demographic backgrounds. The study also may be less generalisable to Māori in Aotearoa New Zealand, who suffer disproportionally high rates of insomnia.8 Further research should be done with a larger sample size to address these areas. Targeted research of indigenous ethnic groups is important for future studies, as the treatment barriers experienced by ethnic minority groups are possibly different or more pronounced in comparison. Furthermore, patients’ survivorship experience may be different between ethnic groups. As an additional limitation, our sample has an average body mass index of 30.2 kg/m2, which is in the obese range. This is unsurprising as New Zealand has the third-highest obesity rate in the OECD. Thus, many of these patients could probably have an underlying obstructive sleep apnoea disorder which can cause sleep problems even,9, 10 even before they receive PCa treatment.
We also would like to note that the strategies we asked for had not been well-tested in PCa populations. However, some treatments like CBT and mindfulness have been well-investigated in breast cancer populations. A recent literature review11 highlighted that CBT, mindfulness, and yoga are effective in alleviating sleep disturbance in breast cancer populations. Future research should assess how effective these treatments are in PCa patients population, and identify enablers and barriers to using them for improving sleep.
As a concluding note, many PCa patients experience insomnia symptoms, and they may have their personal preference on how to manage their sleep. Clinicians should be aware that some patients are not willing to use medication, and they could advise them about non-pharmacological treatment like CBT, which has been shown to have good efficacy in other cancer patients.
Written by: Shenyll Delpachitra, Angela Campbell, Erik Wibowo
Department of Anatomy, University of Otago, Dunedin, New Zealand. WellSleep, Department of Medicine, University of Otago, Wellington, New Zealand. Department of Anatomy, University of Otago, New Zealand.
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- Savard J, Hervouet S, Ivers H. Prostate cancer treatments and their side effects are associated with increased insomnia. Psycho-Oncology. 2013;22(6):1381-8.
- Savard J, Ivers H, Savard M-H, Morin CM. Cancer treatments and their side effects are associated with aggravation of insomnia: Results of a longitudinal study. Cancer. 2015;121(10):1703-11.
- Gonzalez BD, Small BJ, Cases MG, Williams NL, Fishman MN, Jacobsen PB, et al. Sleep disturbance in men receiving androgen deprivation therapy for prostate cancer: The role of hot flashes and nocturia. Cancer. 2018;124(3):499-506.
- Krakow B. Nightmare Complaints in treatment-seeking patients in clinical sleep medicine Settings: Diagnostic and treatment implications. Sleep. 2006;29(10):1313-9.
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- Garland SN, Johnson JA, Savard J, Gehrman P, Perlis M, Carlson L, et al. Sleeping well with cancer: A systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatric Disease and Treatment.. 2014;10:1113-23.
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- Zeichner SB, Zeichner RL, Gogineni K, Shatil S, Ioachimescu O. Cognitive behavioral therapy for insomnia, mindfulness, and yoga in patients with breast cancer with sleep disturbance: A literature review. Breast Cancer (Auckl). 2017;11:1178223417745564.