SLEEPJ, 2021, 1–3
https://doi.org/10.1093/sleep/zsab202
Editorial
A step in the right direction: making cognitive-
behavioral therapy for insomnia more accessible to
people diagnosed with cancer
Sheila N. Garland1,2,*,
Department of Psychology, Faculty of Science, Memorial University, St. John’s, NL, Canada and 2Discipline of
1
Oncology, Faculty of Medicine, Memorial University, St. John’s, NL, Canada
*Corresponding author. Sheila N. Garland, Department of Psychology, Memorial University, 232 Elizabeth Ave, St. John’s, NL A1B 3X9, Canada. Email:
sheila.garland@mun.ca
Insomnia is a prevalent and persistent condition that affects
roughly half of all people diagnosed with cancer. As such, de-
mand for insomnia treatment far exceeds available resources.
A  dearth of providers trained in sleep interventions and inad-
equate access to services continues to plague the field of be-
havioral sleep medicine [1], but for those whose insomnia began
or was worsened by a cancer diagnosis, treatment is even more
elusive [2]. Stepped care has been proposed as a possible ser-
vice delivery model for increasing access to scarce Cognitive
Behavioral Therapy for Insomnia (CBT-I) services [3]. In this
issue, Savard et al. used a noninferiority design to test whether
the short- and long-term effects of a stepped care approach to
deliver CBT-I (StepCBT-I) was not significantly worse than pro-
fessionally administered treatment (StanCBT-I) in a cancer
setting [4]. Their CBT-I protocol was a 6-week intervention com-
bining stimulus control, sleep restriction, cognitive restruc-
turing, and sleep hygiene education. They found that StepCBT-I
was not significantly inferior to StanCBT-I with overall reduc-
tions in Insomnia Severity Index (ISI) scores of −8.16 and −9.24,
respectively, and that these improvements were durable up to
1 year. Improvements were also observed on measures of anx-
iety, depression, fatigue, and quality of life. These reductions are
consistent with the overall data for the efficacy of CBT-I 5, fur-
ther strengthening the evidence for the use of CBT-I with those
impacted by cancer.
Clinical guidelines recommend screening and treatment of
insomnia in cancer settings [5–7], but individual providers and
organizations often lack clear treatment pathways based on this
information. An important feature of the model tested by Savard
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Editorial
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et al. was that initial treatment was tailored based on symptom
severity (also known as a stratified stepped care model). In the
Savard et al. trial, those who were randomized to the StanCBT-I
group (n = 59) received 6 weekly 50-minute face-to-face sessions
of CBT-I, whereas those who were randomized to the StepCBT-I
(n  =  118) group were further stratified by insomnia severity. In
Step 1, those with less severe symptoms (as indicated by an ISI
score of ≧8 but <15) were provided with a web-based CBT-I pro-
gram called Insomnet, while those with more severe insomnia
symptoms (as indicated by an ISI score of ≧15) were provided
with face-to-face treatment. Compared with a pure stepped
care model where everyone starts out with the least intensive
intervention and then moves upwards, this stratification allows
patients to receive more timely delivery of the appropriate in-
tensity of intervention.
Another unique feature of the Savard et al. trial was that the
treatment algorithm was able to adapt to the needs of the pa-
tient in cases where there was an incomplete therapeutic re-
sponse to the lower-level intervention. In Step 2, only those who
were unremitted (defined as an ISI score of ≧8) were given up
to three face-to-face booster sessions dedicated to individual
problem solving and motivational interviewing to address diffi-
culties with implementation of specific aspects of treatment. The
availability and utilization of booster sessions in the StepCBT-I
group has clinical applications to more efficiently utilize pro-
vider time. After Step 1, 72% of StanCBT-I and 58% of StepCBT-I
patients were remitted. Of those individuals assigned to the
StepCBT-I group, 66% of patients who began with face-to-face
sessions experienced remission, compared with 51% of patients
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who received the web-based treatment. The acceptance of
booster sessions also appeared to differ by group. Of those in-
dividuals who received web-based CBT-I as their first step, 27%
accepted one or more booster sessions, compared with only 8%
of those who received face-to-face CBT-I as their first step. This
suggests that face-to-face therapy will remain necessary for a
proportion of patients who need more individualized treatment
because of challenges with motivation and/or more complex
clinical presentations. Accordingly, the preponderance of evi-
dence still suggests that face-to-face intervention produces out-
comes that exceed those from web-based or digital treatment
[8–10]. As such, entry-level interventions such as the program
tested by Savard et al. should not be used to replace face-to-face
service provision by skilled practitioners. Rather, less-intensive
interventions, when applied appropriately, can make treatment
more accessible and more efficiently utilize scarce resources.
Only one other study has assessed the use of a stepped care
model to treat insomnia in cancer survivors [11]. In Step 1 of
this study, participants with an ISI score of ≧12 received a single
sleep education session. If participants were still symptomatic
1  month later, they were offered a group treatment program
consisting of three sessions. Participants were classified as “re-
sponders” if their ISI score improved by ≧6 points and as “re-
mitted” if their post-treatment ISI score was <12. Close to half
(45%) of participants responded to Step 1, but they were more
likely to have less chronic and less severe insomnia compared
with the 87% response rate in those people who proceeded to
Step 2. Interestingly, 53% of those who did not respond to Step
1, chose not to move on to Step 2, suggesting that an ineffective
first step for those with more chronic and severe insomnia may
influence willingness to engage with a more intensive treatment
at a future date. Other evaluations of stepped care programs for
psychological disorders have also reported significant drop-out
at the initial step when the patient did not respond to the low
intensity intervention [12]. As a result, there have been calls to
include consideration of patient treatment preference when
determining the optimal initial step in the stepped care model.
Despite CBT-I being the recommended treatment for in-
somnia in people diagnosed with cancer [7, 13], dissemination
and implementation of CBT-I in cancer treatment centers re-
mains subpar. In a survey of 25 adult survivorship programs
at National Cancer Institute-designated cancer centers, not a
single cancer center reported that at least 50% of their patients
were receiving optimal treatment for their insomnia [14]. More
than half of the centers surveyed screened less than 25% of
people diagnosed with cancer for sleep-related issues, and 72%
of centers lacked on-site access to a provider specializing in the
treatment of sleep disorders [14]. When problems were identi-
fied in these centers, medications were the most common treat-
ment option, whereas only 13% of cancer centers referred their
patients for CBT-I [14]. As a result of this knowledge to action
gap, cancer survivors with insomnia are underdiagnosed, mis-
managed, and left to suffer the long-term effects of a highly
treatable condition.
Recent efforts have tried to understand the discrepancy
between the evidence for CBT-I and its implementation into
real-world clinical practice. Barriers to the implementation of
guideline-based practice for insomnia in cancer survivors have
been identified at the patient, clinician, and institutional/soci-
etal levels [15]. Some barriers include (1) lack of education about
the importance of sleep health; (2) lack of awareness of the
evidence for nonpharmacological treatment; (3) financial con-
straints (e.g., lack of insurance coverage); (4) access and prac-
tical issues (e.g., shortage of qualified clinicians); and (5) existing
attitudes and beliefs (e.g., medication is the only treatment
available) [15]. Other settings have had more success with im-
plementation of CBT-I by identifying and engaging sleep cham-
pions, eliciting support from leaders, integrating services within
existing clinical care, and having well-defined referral pathways
[16].
As a clinician and researcher in sleep and cancer, it is
frustrating that an effective treatment for insomnia, which can
be implemented in creative and flexible ways, is not being uni-
versally utilized in organizations with the explicit purpose of
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helping people recover from, or live well with, cancer. Insomnia
in those diagnosed with cancer is far from benign and can have
immediate-, short-, and long-term consequences. In the imme-
diate and short term, insomnia can worsen levels of pain, fa-
tigue, anxiety, and depression [17] and increase risk of infections
[18]. In the long term, insomnia significantly contributes to poor
quality of life up to 10 years postdiagnosis [19], leads to increases
in healthcare expenditures and work absenteeism [20], and may
contribute to poorer treatment response and greater overall
mortality [21]. The study by Savard et al. is a much-needed dem-
onstration that a stepped care approach to treating insomnia
in cancer survivors is effective and can make efficient use of
limited resources. Considering the recent American Academy of
Sleep Medicine declaration that insufficient sleep and untreated
sleep disorders are detrimental for health and well-being [22],
cancer-treatment organizations need to “step up” and ensure
that patients can avail of evidence-based interventions to im-
prove their sleep, cancer experience, and quality (and possibly
quantity) of life.
Disclosure Statement
Financial disclosure statement: All authors declare no com-
peting interests.
Nonfinancial disclosure statement: All authors declare no
competing interests.
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