Cognitive Behavioral Therapy More Effective Than Acupuncture for Mild Insomnia in Cancer Survivors
Insomnia is a common and debilitating disorder that affects more than 50% of cancer survivors. Acupuncture and cognitive behavioral therapy (CBT) are 2 interventions that have been shown to improve insomnia symptoms in cancer survivors. A new study suggests that CBT may be more helpful for milder cases of insomnia.
“Patients in the hospital get interrupted a lot, but people who are at home and on steroids often have difficulties with sleep. There are certainly anxiety-related sleep disorders in patients with advanced cancer who worry about the future,” said Thomas W. LeBlanc, MD, MHS, FAAHPM, Associate Professor of Medicine, Duke Cancer Institute, Durham, NC, at the 2018 Best of ASCO meeting in Chicago. “This is one of the most commonly reported symptoms and problems in all cancer patients in any studies looking at patient-reported outcomes.”
The clinical trial enrolled 160 posttreatment cancer survivors with clinically diagnosed insomnia disorder for an intervention that lasted 8 weeks. The acupuncture intervention involved stimulating body points with needles, and CBT involved sleep restriction, stimulus control, cognitive restructuring, relaxation training, and education.
Each arm had 80 patients, and all patients had completed cancer treatments at least 1 month before the study.
All study participants had an Insomnia Severity Index score of more than 7 and a Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition insomnia diagnosis. Patients were allowed to take antidepressants, hypnotics, or sedatives if their dose had been stable 6 weeks before the study.
At a follow-up assessment conducted at 20 weeks, the investigators found that CBT reduced insomnia severity by 10.9 points, according to the Insomnia Severity Index, compared with 8.3 points with acupuncture.
Furthermore, patients with mild insomnia were more than 4 times more likely to respond to CBT than to acupuncture (85% vs 18%, respectively), whereas patients with moderate-to-severe insomnia had similar response rates to the 2 interventions (75% vs 66%).
“There did seem to still be a trend toward CBT working a bit better than acupuncture for moderate-to-severe insomnia, but it wasn’t a statistically significant difference,” Dr LeBlanc noted. “So in folks who have more mild insomnia, maybe we should favor CBT, but otherwise, both do seem to be effective and impactful,” he added.
Finally, both groups had similar improvements in quality-of-life measures of physical and mental health during the study.
Lack of Access to CBT
According to Dr LeBlanc, although the benefits of CBT for sleep difficulties are well-documented, many cancer centers do not offer it to their patients. And even when patients do have access to CBT programs, they often face financial issues for lack of insurance coverage, reimbursement, and lack of availability in the clinic.
Recently, there have been efforts to digitize CBT and target anxiety- and sleep-related issues through the use of apps and web-based interventions. “This is promising, and may help to increase access and decrease cost,” Dr LeBlanc said.
By contrast, acupuncture is more widely available to patients through their cancer centers. Recent data suggest that acupuncture is offered at more than 70% of cancer centers in the United States, and has a growing body of evidence regarding its beneficial effect on pain, hot flashes, and related sleep disturbances.
Although CBT was shown to be slightly more effective in this particular randomized clinical trial, acupuncture is also a worthwhile and viable treatment option for sleep disturbance in cancer survivors. According to Dr LeBlanc, “both interventions led to significant improvements from baseline in overall insomnia scores, with sizable efficacy for both intervention arms.”
This study was originally presented at ASCO 2018 by Jun J. Mao, MD, MSCE, Chief, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center, New York City.
The PD-L1 inhibitor durvalumab (Imfinzi) showed an overall survival benefit in patients with unresectable stage III non–small-cell lung cancer (NSCLC) in the phase 3 PACIFIC trial.
Anxiety is a common symptom in patients with advanced cancer, and is associated with reduced quality of life, increased symptom burden, poor medication adherence, and suboptimal treatment decisions at the end of life. Anxiety also tends to cluster with disease- and treatment-related side effects such as fatigue, pain, breathlessness, nausea, vomiting, and sleep disturbance.