The Symptom Cluster of Sleep, Fatigue and Depressive Symptoms in Breast Cancer Patients: Severity of the Problem and Treatment Options

Abstract

Breast cancer is the most commonly diagnosed cancer in women. Insomnia is a significant problem in breast cancer patients, affecting between 20% to 70% of newly diagnosed or recently treated cancer patients. Pain, fatigue, anxiety, and depression are also common conditions in breast cancer and often co-occur with insomnia in symptom clusters, exacerbating one another, and decreasing quality of life (QOL). There have been no clinical trials of drugs for sleep in cancer. Cognitive behavioral psychotherapies on the other hand, have shown some of the most positive results in alleviating the distressing symptoms that often accompany the breast cancer experience, but even these studies have not targeted the symptom cluster. Pharmacological as well as non-pharmacological treatments need to be explored. It might be that a combined pharmacological and behavioral treatment is most efficacious. In short, substantially more research is needed to fully understand and treat the symptom cluster of insomnia, fatigue, pain, depression and anxiety in breast cancer.

Figure 1

This is an actigraph record of a 57 year old woman with breast cancer, recorded for three days before and three days during the first week of chemotherapy. Each row represents 24 hours of data. Day 1 through Day 3 represent the recording conducted before the start of chemotherapy (baseline), starting at 8 am on Day 1 and ending at 9 am on the last day. Day 8 through Day 11 are the first three days of the first week of treatment (week 1), starting at 5:30 am on Day 8 and ending at 9 am on the last day. Each vertical line represents one second (called one epoch), and the height of the bar indicates the total amount of movement, or wrist activity, during that minute. The higher the bar, the more movement there is. During the night, when the woman was asleep, there are fewer and shorter vertical bars. During the day the lines are much more dense and higher. The red horizontal bars below the vertical black bars indicate the wake time, and the rest white blank areas between the red bars indicate sleep time. At baseline, the patient went to bed at around 10 pm and woke up the next morning at around 5 to 6 am. During cycle 1 week 1, the patient went to bed at about 9 pm and got up at about 5:30 am. Compared to baseline, there was more movement during the nights of cycle 1 week 1, indicating disrupted sleep. On the other hand, compared to baseline, there was less movement during the days of week 1, especially during the third day, indicating more inactivity which might represent napping. More movement during the night and less movement during the day, indicates disturbed sleep, as well as disrupted sleep/wake circadian rhythms.

Figure 2

Scatterplot of total fatigue (MFSI-SF total score) and the timing of the peak of the circadian rhythm during the treatment week of cycle 1 of chemotherapy (r=0.40; p=0.016). The plot shows that the more fatigue reported by the women (that is, the higher the score on the MFSI-sf), the later the peak of their circadian activity rhythm (that is, the later they went to bed and the later the awoke in the morning).