Lung cancer survivors have a particularly high risk of developing sleep disorders relative to other cancer survivors. Prevalence estimates for insomnia in lung cancer survivors is over 50% and as high as 80% and insomnia persists an average of eight years after diagnosis. Smoking history, pre-existing chronic obstructive pulmonary disease (COPD), and the effects of lung cancer treatment, in particular, partial lung resection and postoperative radiotherapy can result in impaired pulmonary function resulting in hyperarousal from pain, cough and dyspnea leading to a worsening of insomnia. To date, little research exists on strategies to effectively reduce insomnia in lung cancer survivors, especially in the application of cognitive behavioral therapy for insomnia (CBT-I) at the bedside by nurses. Cognitive behavior therapy for insomnia (CBT-I) results in clinically significant improvements in insomnia symptoms without the negative effects commonly reported with hypnotic medications. While CBT-I is a well-established and effective treatment for insomnia in many diseases, there remains a pressing need to study CBT-I in lung cancer survivors because they are different from other cancer patients due to their previous or current tobacco smoking history, presence of COPD, and diminished pulmonary capacity. The appropriate dose and frequency of CBT-I in comorbid insomnia has not been determined. CBT-I consists of sleep restriction, stimulus control, relaxation, sleep hygiene education and cognitive therapy that focuses on dysfunctional sleep-related thoughts and unhelpful sleep behaviors that may exacerbate insomnia. This study proposes a multi-tiered, translational approach to address specific needs of lung cancer survivors.
Aim 1 will determine the efficacy of a standard CBT-I treatment protocol in lung cancer survivors.
Aim 2 of the study proposes to translate CBT-I for patients with lung cancer into nursing practice by performing a formative evaluation of the implementation focused on (a) characterization of the patient and patient-provider facilitators and (b) knowledge and skills among staff nurses. Translation is an important step for embedding this intervention into standard nursing care. One hundred forty lung cancer survivors will be randomized to either CBT-I or attention control. Sleep, mood, functional status and quality of life will be evaluated before and 5-weeks after the intervention. The primary outcome will be self-reported sleep efficiency (time asleep/time in bed;>85%=good sleep). This study will demonstrate the application and adaptability of an effective, well-known intervention to the lung cancer population for the first time and inform a larger study to evaluate implementation strategies that will promote the dissemination and sustainability of this intervention. The ultimate goal is to offr practical, adaptable and implementable interventions that improve the quality of life for the countless lung cancer patients who suffer profound effects of insomnia without any currently-available treatment modified for them and their disease. Thus, the rapid translation to clinical application makes this appealing on the clinical front but has significant promise at the individua patient level as well.
Advances in cancer biology, early diagnosis and treatment improvements have increased the opportunities for long-term survival. There are now nearly 500,000 lung cancer survivors in the US and they have a particularly high risk of developing sleep disorders relative to other cancer survivors. Effective interventions with low patient burden and low cost are desperately needed to improve sleep in populations with complex symptomatology, such as lung cancer survivors.