Breast Cancer Research and Treatment

https://doi.org/10.1007/s10549-020-05635-0

REVIEW

Evaluation and management of insomnia in women with breast cancer

Agnes Kwak1 · Jamie Jacobs1 · Dana Haggett1 · Rachel Jimenez1 · Jeffrey Peppercorn1,2

Received: 8 February 2020 / Accepted: 7 April 2020

© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose  Insomnia is a common issue among patients with breast cancer with a potentially devastating impact on quality of
life. It can be caused or exacerbated by multiple disease and treatment-related factors. Despite the prevalence and impact of
insomnia, it is rarely addressed systematically in the oncology clinic. We conducted a comprehensive review of insomnia to
guide clinical care of patient’s with breast cancer and insomnia.
Methods  This manuscript reviews the prevalence, etiology, emerging science and both non-pharmacologic and pharmaco-
logic options for treatment of insomnia among patients with breast cancer.
Results  Multiple factors contribute to insomnia among patients with breast cancer including endocrine therapy and hot-
flashes, pain and discomfort from local therapy, and fear of recurrence. If we do identify insomnia, there are treatment options
and strategies available to help patients. In particular, there is now a considerable body of evidence supporting the use of
psychosocial interventions and behavioral treatments, such as cognitive behavioral therapy for insomnia (CBT-I), yoga, and
mind-body programs. It is also important for oncology providers to be educated regarding available pharmacologic therapies
and emerging data for cannabis-based therapy.
Conclusion  This manuscript provides an up-to-date and comprehensive review of the prevalence, etiology, and treatment
approaches available for insomnia for clinicians treating patients with breast cancer. We also address strategies and goals
for cancer care delivery and future research.

Keywords  Insomnia · Breast cancer · Cognitive behavioral therapy · Review · Survivorship

Introduction Emotional distress, discomfort following surgery, and

Insomnia, defined as difficulty falling asleep, staying asleep,
or waking up too early at least three times per week for at
least 3 months, is one of the most common problems expe-
rienced by patients with breast cancer [1]. Unfortunately
it often goes unrecognized and unaddressed in the course
of routine clinical practice [2]. It is common both in the
general population and among all patients with cancer, but
has proven to be particularly prevalent among patients with
breast cancer, making this a special concern for breast cancer
clinicians [3, 4].
* Jeffrey Peppercorn
Jpeppercorn@mgh.harvard.edu
1
Massachusetts General Hospital Cancer Center, 55 Fruit St,
Boston, MA 02114, USA
2
MGH Cancer Survivorship Program, Massachusetts General
Hospital, Harvard Medical School, Boston, USA
treatment side effects, most prominently those related to
endocrine therapy, all contribute to insomnia among patients
with breast cancer. Insomnia, in turn, can contribute to poor
quality of life, impaired daily functioning and productivity,
worsening physical and emotional distress, and frequent uti-
lization of healthcare services [5–7]. Despite the importance
of this issue, only 56% of United States cancer centers report
any systematic screening for insomnia [2]. Even among cent-
ers with screening programs, approximately 75% of patients
remain unscreened [2]. The oncology literature and prac-
tice have not kept pace with the increased understanding of
the prevalence and impact of insomnia and of the evidence
base supporting behavioral medicine and other non-pharma-
cologic approaches to address this common problem. This
paper is intended to provide the practicing oncologist with
a practical review of the diagnosis, etiology, and treatment
options for insomnia among patients with breast cancer. We
also discuss emerging data, research priorities and health

13
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services delivery tools that can inform clinical practice and
establishment of dedicated screening and treatment services.
The prevalence of insomnia
Insomnia is a common problem in the general population
and tends to be more frequent in women compared to men.
This gender difference, while incompletely understood, may
partially explain the higher prevalence in the breast cancer
population [8, 9]. However, compared to the general popu-
lation, patients with cancer report up to three times higher
rates of insomnia, and the highest prevalence is found
among patients with breast cancer. Prevalence estimates
vary depending upon how insomnia or sleep disturbance is
defined and evaluated. In one survey of over 900 patients
across six cancer centers, 38% of patients with breast cancer
reported significant insomnia, compared to 31% of patients
with gastrointestinal, genitourinary, gynecologic, lung, or
skin cancers [3]. Other studies suggest that over 60% of
patients with breast cancer experience reduced sleep times
and frequent sleep disturbances [10].
Insomnia is seen among both breast cancer survivors
and patients living with advanced breast cancer [11]. While
insomnia is clearly present in many patients prior to diag-
nosis, interviews with patients undergoing radiation therapy
for breast cancer found that over 30% of patients developed
insomnia as a new problem and an additional 25% reported
worsening of chronic insomnia [4]. Once established, insom-
nia is often persistent. A 12-month longitudinal study found
that following initial breast cancer therapy with curative
intent, most patients saw improvements in psychological
measures such as anxiety, distress, and depression over time,
but continued to suffer from insomnia [9].
Causes of insomnia among patients
with breast cancer
There are many possible causes of insomnia and it can
be difficult to identify a single etiologic factor for a given
patient. In addition to the stress and uncertainty that often
accompany the diagnosis of cancer, several treatment-related
factors are often associated with insomnia. Vasomotor symp-
toms, including hot flashes and night sweats, are common
as a result of both chemotherapy-induced amenorrhea and
endocrine therapies, such as ovarian suppression, tamox-
ifen, and aromatase inhibitors. These vasomotor symptoms
may contribute to the onset of insomnia or exacerbate a pre-
existing condition.
Approximately half of patients receiving adjuvant endo-
crine therapy report insomnia, and hot flashes appear to be
a contributing factor for many of these patients [12]. In a
13
Breast Cancer Research and Treatment
survey of 222 postmenopausal women with breast cancer,
64% reported hot flashes, 44% reported night sweats [13].
For most of these women, these symptoms were associated
with trouble sleeping. Savard et al. measured nighttime hot
flashes and sleep in breast cancer survivors with chronic
insomnia using skin conductance and polysomnography and
observed that the time surrounding hot flashes was associ-
ated with greater arousal and lighter sleep stages [14]. The
sudden onset of menopause, as induced by breast cancer
therapy, has also been associated with more severe sleep dis-
turbance than the gradual onset of natural menopause [15].
While some degree of sleep disturbance is clearly con-
nected to vasomotor symptoms, some patients report insom-
nia in the absence of hot flashes. While there has been little
research investigating the direct impact of endocrine therapy
on sleep, estrogen levels have been shown to independently
impact circadian rhythms [16]. This impact of endocrine
therapy on insomnia distinct from vasomotor symptoms
merits further exploration. Another common symptom fol-
lowing breast cancer therapy is breast and chest wall pain.
Some degree of chronic pain has been reported in approxi-
mately half of patients following breast surgery and it is
often associated with sleep disturbances [17]. If patients do
report sleep problems, it is also important to consider other
health issues including sleep apnea, hypothyroidism, sub-
stance abuse, obesity, respiratory disorders, and endocrine
dysfunction [18].
Just as insomnia can contribute to distress, the psycho-
logical impact of breast cancer can also lead to insomnia.
Depression, anxiety, and stress are often observed in paral-
lel with sleep disturbance. In a study of patients experienc-
ing insomnia, 87% cited the stress surrounding their cancer
diagnosis as a major reason for sleep difficulties [4]. In addi-
tion, a longitudinal study in women with metastatic breast
cancer found that higher baseline depression and stress pre-
dicts development of sleep difficulties [19]. Patients report-
ing higher depression and stress levels also reported issues
with sleep onset, nighttime disturbances, daytime sleepiness,
and decreased number of hours of sleep. Finally, fear of
recurrence is a very common problem for cancer survivors,
including patients with breast cancer, and it is also associ-
ated with insomnia [20, 21].
The importance of addressing insomnia
It is important to identify and address insomnia, both
because of its immediate impact on distress and quality
of life and because of the potential downstream effects
on physical and emotional health (see Fig. 1) [22]. While
there has been limited evaluation of practice patterns
regarding insomnia in the oncology clinic, the evidence
to date suggests that this issue is often neglected. Patients
Breast Cancer Research and Treatment
Hot flashes
Pain
Endocrine
impact on Insomnia
circadian rhythm
Depression,
anxiety, distress
Fear of cancer
recurrence
Fig. 1  Conceptual model for development and impact of insomnia among patients with breast cancer
report that providers rarely pay attention to sleep concerns
and that even when insomnia is evaluated, discussions are
often brief and treatment recommendations tend to focus
on prescription medications [23]. Limited attention to
insomnia could be due to a perception that this is a com-
mon issue, often unrelated to cancer care, and a sense that
there is little that the oncologist can do to help. Among
25 National Comprehensive Cancer Network (NCCN) and
National Cancer Institute (NCI) designated US cancer
centers surveyed regarding management of insomnia, 72%
of sites reported that a major barrier to addressing insom-
nia was lack of appropriate specialists for referral [2].
If clinicians do not ask about this issue, patients may not
bring it up during a clinic visit. A multi-site sleep study
found that a minority of patients experiencing insomnia
would bring it up if not prompted by their care team [24].
There are many reasons insomnia can go underreported.
Patients may consider insomnia a minor issue compared
to their cancer, or they may believe that discussion will
only lead to an additional drug [24, 25]. Patients may be
unaware of behavioral therapy and lifestyle interventions
for insomnia.
While the strongest argument for addressing insomnia
in clinic is based on its well-documented impact on qual-
ity of life, emerging data suggests it could also be linked
to disease outcomes. A longitudinal, prospective study of
breast cancer patients by Palesh et al. found that baseline
sleep quality, particularly sleep efficiency, as measured by
sleep logs and actigraphy, correlated with modest improve-
ments in overall survival [26]. This association persisted
even when controlling for age, breast cancer subtype, prior
treatment, and depression.
Low energy
levels
Fatigue
Poor productivity
and functioning
Depression
and anxiety
Poor cognitive
functioning
Several studies investigating how sleep could impact
disease outcomes have examined the immune system and
inflammatory mechanisms. Evaluation of cell count and
activity of white blood cells, natural killer (NK) cells,
lymphokine-activated killer (LAK) cells, and interleukin-2
(IL-2) in healthy participants demonstrated that partial
sleep deprivation results in suppression of NK cell activity
and IL-2 production, which are instrumental in identifying
and attacking diseased cells [27]. In a prospective study
of 125 women with metastatic breast cancer participat-
ing in a group psychotherapy trial, Sephton et al. found
that circadian-related cortisol patterns and the associated
suppression of NK cell activity correlated with inferior
survival, suggesting a potential immune-mediated impact
of sleep disturbance [28]. In addition, sleep problems can
contribute to early discontinuation of endocrine therapy,
which, in turn, will increase the risk of breast cancer
recurrence [29].
Observational studies evaluating the association
between insomnia and the risk of breast cancer have
shown inconsistent results [30–32]. In an innovative effort
to evaluate the association between recurrence risk and
sleep, Thompson et al. compared self-reported sleep dura-
tion prior to diagnosis among 101 patients with early-stage
breast cancer and their risk of cancer recurrence based on
the multi-gene predictor, OncotypeDx. They found that
fewer hours of sleep correlated with higher recurrence risk
scores among postmenopausal women, even when control-
ling for age, physical activity and body mass index [33].
13
 Breast Cancer Research and Treatment

How to identify insomnia in practice
Given the multiple demands on breast cancer follow-up
visits, it can be easy for a common, but not immediately
life-threatening condition, like insomnia, to be overlooked.
While some demographic and psychological features have
been linked to risk of insomnia, including being widowed or
separated, lower education or income level, and poor cogni-
tive management strategies such as self-blame and catastro-
phizing, insomnia can impact any patient [4, 34].
Currently, there is no standard tool that is routinely used
to evaluate insomnia in the clinic. The NCCN guidelines
suggest asking all cancer survivors: “Are you having trouble
falling asleep, staying asleep, or waking up too early?” as
part of a battery of survivorship-related questions, but there
is no evidence that this has been widely adopted in practice
[2, 23]. This tool, or a modification of it, is easy to imple-
ment and can be done with minimal resources [35].
For practices seeking to implement a more detailed sleep
assessment, there are several validated tools that can be
used. These include the Insomnia Severity Index (ISI) and
the Pittsburgh Sleep Quality Scale (PSQI) [36, 37]. The ISI
is a seven-question survey that is commonly used to identify
and quantify the severity of insomnia over the past 2 weeks.
Using a five-point Likert-type scale, it asks questions regard-
ing difficulty falling asleep and maintaining sleep, satisfac-
tion with sleep, noticeability of sleep disturbances, and
distress. Out of total possible score of 28, a score of 8 is gen-
erally regarded as the optimal cut-off for clinical significance
and a score of 15 indicates chronic insomnia syndrome. The
PSQI is a 19-question instrument that assesses seven com-
ponents to measure sleep quality over the past 4 weeks. It
evaluates sleep quality, efficiency, duration, and latency. It
also asks questions regarding daytime dysfunction, sleep dis-
turbances, and medication use. Each of the seven domains
yields a score between 0 and 3, which are summed together
to give a total possible Global Sleep Quality score of 21,
with higher scores indicating poorer sleep quality [37]. For
clinical purposes, the ISI has the advantage of brevity and
relatively simple scoring.
Sleep diaries can also be used as tools to moni-
tor patient’s sleep patterns. They allow for longitudinal
comparisons, symptom tracking, and self-management.
Patients rate their sleep quality, record their thoughts,
and report sleep measures, such as time it takes to fall
asleep and number and duration of nighttime disturbances
[38]. A Consensus Sleep Diary has been adopted from the
collaboration of an expert panel on insomnia to create a
standardized tool for research and clinical purposes [39].
Core questions ask about time to fall asleep, duration and
number of awakenings, total length of sleep, and quality
of sleep. Expanded versions of the diary include questions
that inquire about feelings of restfulness and frequency
of naps, alcoholic drinks, caffeinated drinks, and medica-
tions. A unique strength of sleep diaries is that they allow
for a more detailed understanding of a patient’s experi-
ence. However, sleep diaries are subject to recall bias, may
overestimate insomnia, and are time-consuming.
Polysomnography, which relies on objective physi-
ologic measurements such as brain waves and blood oxy-
gen levels, may offer valuable diagnostic information for
insomnia. In an outpatient study of 100 subjects, poly-
somnography-derived measurements of total sleep time
were found to be greater compared to time reported in
participant sleep diaries, and were useful in diagnosing
subjective insomnia [40]. While polysomnography can be
a helpful tool for evaluation, confounding factors, such as
the laboratory environment and the fluctuating severity
of insomnia, limit the accuracy of polysomnography as a
primary diagnostic tool.
Therapy for insomnia
Treatment options for insomnia include pharmacologic
therapy, behavioral and psychosocial interventions, and
physical activity. It is also important to educate all patients
about good sleep hygiene (See Table 1) [41].
The choice of a drug or behavioral intervention will
vary largely on patient preference, clinician experience,
and consideration of the patient’s comorbidities. While
many medications for insomnia are safe if used appro-
priately, side effects are possible with any drug, and
some options have potential for more serious toxicity and
dependence.

Table 1  Strategies for good sleep hygiene: SLEEP

S Schedule Try to go to bed and wake up on a consistent schedule

L Light Expose yourself to bright light during the day, keep the bed room dark, and avoid lights from cell phones,
TVs and other electronics before bed and during the night
E Environment Keep the bedroom cool, comfortable, dark, and relaxing
E Exposures Avoid alcohol, nicotine, caffeine, and large meals close to bedtime
P Physical activity Exercise during the day or late afternoon and avoid vigorous exercise immediately before sleep

13
Breast Cancer Research and Treatment

Behavioral and lifestyle based treatment In addition to CBT-I, other non-pharmacologic interven-

options for insomnia
A non-exhaustive list of the many non-pharmacologic
approaches to insomnia, which are often preferred by
patients over medications, is provided in Table 2 [42]. The
most important intervention for breast cancer clinicians
to be aware of is cognitive behavioral therapy (CBT). The
American College of Physicians now recommends CBT-
Insomnia (CBT-I) as the first line of treatment for chronic
insomnia [43]. Multiple randomized controlled trials sup-
port the role of CBT-I as a long-term treatment option.
CBT-I involves several components, including stimulus
control, sleep restriction, and sleep education/hygiene,
which have been found to significantly reduce the amount
of time awake after sleep onset [44]. It has been shown to
improve physical and cognitive function, sleep attitudes,
and sleep hygiene knowledge for patients with breast can-
cer [45]. Face-to-face CBT-I can also improve comorbid
conditions, such as fatigue, anxiety, and depression [46].
For practices without access to a trained therapist, tele-
phone-delivered CBT-I is an accessible and cost-effective
treatment option. Findings from a randomized controlled
trial reported significant enhancements in sleep cognitions
and efficiency, and improved daytime fatigue, depression,
and anxiety symptoms with telephone CBT-I [47]. Inter-
net-based CBT (iCBT) has also shown preliminary effi-
cacy for insomnia among patients with breast cancer [48].
A recent study compared the efficacy of therapist-guided
versus self-managed iCBT for menopausal symptoms,
including insomnia, among breast cancer survivors [49].
With or without clinician guidance, iCBT produced both
short-term and long-term clinically significant positive
results for the perceived impact of hot flashes and sleep
quality. While self-managed and digitally-based treatments
can produce significant results, face-to-face CBT-I admin-
istered by a trained healthcare professional is still viewed
as the most effective intervention [44, 50].
tions have shown positive effects on insomnia. Elements of
general Cognitive Behavioral Stress Management (CBSM),
such as relaxation training and cognitive restructuring, can
improve subjective sleep quality in women with breast can-
cer [51]. Mindfulness-Based Stress Reduction (MBSR) pro-
grams, which focus on mindfulness meditation, are designed
to address the distress patients with cancer may experience.
In a randomized trial, MBSR was found to have clinically
significant, yet delayed effects on symptoms of insomnia,
such as sleep latency, nighttime awakenings, and total sleep
time, compared to CBT-I [52]. Benefits of MBSR have been
demonstrated among both patients with breast cancer and
general cancer survivor populations [53, 54].
Physical activity may also help insomnia. A small, ran-
domized trial in women on hormonal therapy for breast
cancer found that a simple walking intervention improved
sleep quality [55]. A randomized trial in breast cancer sur-
vivors reported that aerobic and resistance training exercises
improved self-reported insomnia [56]. Yoga can be consid-
ered as both a mind–body and exercise tool for improving
sleep quality. In a randomized study among 410 cancer sur-
vivors (75% with breast cancer), 4 weeks of yoga demon-
strated improvements in sleep quality, duration, and latency,
as well as nighttime awakenings and daytime dysfunction,
compared to standard care [57]. Patients rated yoga highly
with 90% viewing it as useful and 100% recommending
it for other patients with sleep difficulties. In conjunction
with behavioral therapies, such as CBT-I, lifestyle interven-
tions that promote physical activity can help address sleep
problems.
Finally, acupuncture provides an additional non-phar-
macologic option. A randomized trial of real versus sham
acupuncture among postmenopausal women found that acu-
puncture reduced severe nocturnal hot flashes and associated
sleep disturbances [58]. In a multi-arm, randomized trial
among 180 patients with primary insomnia, acupuncture
was found to be superior to both sham acupuncture and to
a benzodiazepine (estazolam), with improvements on the
PSQI [59].

Table 2  Non-pharmacologic interventions for the treatment of insomnia

Non-pharmacologic interventions Evidence of benefit in RCT for Evidence of benefit in patients NCCN recommended for
insomnia? with cancer? insomnia (Category 2A)a

CBT-I Y Y Y
Mind–body Bridging (CNSM, MBSR) Y Y Y
Physical activity Y Y Y
Yoga Y Y Y
Acupuncture Y N N
a
 NCCN recommendations are “Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appro-
priate”

13
 Breast Cancer Research and Treatment

Costs of these non-pharmacologic interventions vary and
may require out of pocket payment. Medicare covers acu-
puncture for chronic pain and private insurance coverage for
varying acupuncture indications is expanding. Acupuncture
sessions typically range from $50 to $100 and courses of
therapy vary but clinical trials have evaluated up to 3 ses-
sions per week for 4 weeks. Medicare advantage and many
private insurance plans also cover fitness classes, including
Yoga. Yoga classes tend to cost $5 to $20 out of pocket.
While CBT-I is recommended by the American College of
Physicians, access to therapists who practice CBT-I can be
a barrier, and insurance coverage varies [60]. Online CBT-I
prices range from as little as $35 to $150 for a course of
treatment [61]. Medicaid coverage varies by state, but may
include behavioral health services, including CBT.
Pharmacologic therapy
Classes of drugs commonly used to treat insomnia are listed
in Table  3. Over-the-counter options include diphenhy-
dramine and melatonin. In a randomized trial among adults
with mild insomnia, 2 weeks of diphenhydramine was found
to improve sleep efficiency by polysomnography and sub-
jective reports of sleep disturbance compared to placebo,
with little toxicity [62]. Melatonin has also been shown to
improve subjective sleep quality in a placebo-controlled
randomized trial among postmenopausal breast cancer sur-
vivors [63].
Common prescriptions for insomnia include benzodiaz-
epines, such as lorazepam, triazolam, flurazepam, temaz-
epam, midazolam, and nitrazepam. A meta-analysis of
45 randomized controlled trials evaluating the efficacy of
these drugs found that benzodiazepines were associated
with increased sleep duration and decreased sleep latency,
when compared to placebo [64]. Short-term or periodic use
of benzodiazepines is generally safe, but long-term use can
lead to dependence and even rebound insomnia [65]. In
addition, diphenhydramine and other anti-histamines with
anti-cholinergic properties are generally well tolerated, but
caution should be taken in older patients or patients with
cognitive impairment.
Non-benzodiazepine hypnotics include zolpidem, eszo-
piclone, and zaleplon. A meta-analysis examining 13 rand-
omized double-blind controlled trials of non-benzodiazepine
drugs compared to placebos reported small but significant
improvements in polysomnographic and subjective meas-
ures of sleep latency [66]. In addition, trazodone, a serotonin
receptor antagonist initially developed as an antidepressant,
has been shown to improve sleep maintenance in rand-
omized controlled trials [67]. The antipsychotic quetiapine is
used off-label for insomnia, but studies evaluating safety and

Table 3  Pharmacologic interventions for the treatment of insomnia

Example medications Evidence of benefit NCCN recom- Potential adverse reactions not an exhaus-
in RCT for insom- mended? (Category tive ­lista
nia? 2A)a

Prescription interventions
Benzodiazepines Lorazepam Y Y Dizziness, headache, lethargy
Triazolam
Flurazepam
Temazepam
Midazolam
Nitrazepam
Non-benzodiazepine hypnotics Zolpidem Y Y Dizziness, headache, somnolence
Eszopiclone
Zaleplon
Antidepressants Trazodone Y Y Dizziness, headache, xerostomia
Mirtazapine
Antipsychotics Quetiapine N Y Dizziness, headache, agitation
Anticonvulsant Gabapentin Y Y Dizziness, lack of balance, blurred vision
Melatonin Receptor Agonist Ramelteon Y Y Dizziness, headache, nausea
Over-the-counter interventions
Antihistamines Diphenhydramine Y N Dizziness, impaired coordination, headache
N N Sedation, asthenia
Y N Diarrhea, vomiting, abdominal pain
a
 NCCN recommendations, included as pharmacologic considerations for sleep disturbance in either the Survivorship or Palliative Care Guide-
lines are “Category 2A: Based upon lower-level evidence, there is uniform NCCN consensus that the intervention is appropriate”

13
Breast Cancer Research and Treatment
efficacy are needed. In addition, for patients with concurrent
anxiety or anorexia, mirtazapine, a tetracyclic antidepressant
can be considered. Gabapentin, an anticonvulsant, can cause
drowsiness and can be considered in patients with chest wall
pain or hot flashes. Finally, ramelteon, a selective melatonin
receptor agonist, may be considered particularly for patients
with difficulty in sleep onset.
In recent years, the use of cannabidiol (CBD) as a sleep-
ing aid has become widespread. In a survey of medical can-
nabis users, 50% reported using cannabis with high con-
centrations of CBD for insomnia [68]. Limited evidence
suggests that high doses of CBD may have a positive impact
on sleep but there have been no large, high-quality clinical
trials to date [69]. One study suggests that CBD effects may
be dose-dependent, with lower doses (15 mg/day) increasing
wakefulness and higher doses (160 mg/day) having sedat-
ing properties [70]. Despite its now widespread availability
and anecdotally increasing use among patients with breast
cancer, there has been surprisingly little research into the
safety and effectiveness of CBD for sleep. There are cur-
rently 10 studies listed in clinicaltrials.gov studying CBD
for symptoms ranging from pain to sleep disturbance among
cancer patients. While there is considerable hype surround-
ing the use of CBD for sleep, there is a clear need for further
research.
Priorities for clinical care delivery and future
research
The prevalence of insomnia among patients with breast can-
cer, coupled with its impact on quality of life and health
outcomes, and the potential for clinical intervention to make
a difference, highlight the need for individual clinicians and
breast cancer programs to systematically address this issue.
Given the many competing priorities of care that patients
face during clinic visits, it is clear that part of the goal must
be to simply educate ourselves and our colleagues about
insomnia and to facilitate screening and referral for inter-
vention. As noted above, the NCCN includes screening for
sleep disorders in the list of questions to ask all survivors at
routine follow-up visits, and this practice could be extended
to periodic assessment of patients living with advanced can-
cer as well [18].
In the oncology clinic, critical research questions include
the timing of insomnia evaluation, utility of sleep hygiene
counseling, and the real-world effectiveness of commonly
used (if not guideline-recommended) medications such as
benzodiazepines. Additionally, because trained psycholo-
gists may not be available in all settings, there is a need
to further evaluate and develop the potential for telehealth
interventions to deliver CBT-I or other interventions for
insomnia [25]. While there have been small studies of CBT-I
among patients with breast cancer, there is a need for a large
randomized trial in this context to demonstrate the value to
patients and to truly change practice. An understanding of
the cost-effectiveness and potential to scale such programs
to meet the needs of the broad group of patients with breast
cancer, not to mention other types of cancer, is also needed.
Summary
Insomnia is a common problem for patients with breast
cancer with adverse impact on health and quality of life,
affecting a majority of patients across all stages of disease.
While insomnia is most commonly treated with medications,
non-pharmacologic approaches such as cognitive behavio-
ral therapy, are safe and effective long-term options. Breast
cancer clinicians can improve the care of their patients by
asking about this common problem, identifying local options
for CBT-I and other non-pharmacologic interventions, and
by educating themselves about prescription and over-the-
counter pharmacologic options. While more research is
needed, particularly on how to best implement screening
and treatment plans in clinic, there is now ample opportunity
to improve outcomes for patients with breast cancer through
evidence-based insomnia care.
Funding  The authors received no funding for this manuscript.
Compliance with ethical standards 
Conflict of interest  Author JP has received research grants from Pfizer.
Author JP has consulted for Athenex. Author JP’s spouse is an em-
ployee of GlaxoSmithKline. No other author has a conflict of interest.
Ethical approval  This article does not contain any studies with human
participants or animals performed by any of the authors.
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