Tai chi chih comparable to standard therapy for breast cancer survivors’ insomnia

Michael R. Irwin

Tai chi chih appeared statistically noninferior to cognitive behavioral therapy for the long-term treatment of insomnia among breast cancer survivors, according to study results.

“Given that standardized tai chi chih is both scalable and community accessible compared with the limited availability of cognitive behavioral therapy in most medical centers, immediate access to tai chi chih would address the need to reduce the morbidity associated with insomnia in survivors of breast and other cancers with treatment benets commensurate with the status quo of clinical treatment approaches to insomnia,” Michael R. Irwin, MD, Cousins distinguished professor of psychiatry and biobehavioral sciences at David Geffen School of Medicine at UCLA, and colleagues wrote.

Irwin and colleagues conducted a randomized, partially blinded noninferiority trial that included 90 breast cancer survivors with comorbid insomnia. Researchers randomly assigned individuals to tai chi chih (n = 45) or cognitive behavioral therapy (n=45).

Outcome measures included insomnia treatment response, insomnia remission, sleep and behavior.

At 15 months, 43.7% of those assigned cognitive behavioral therapy and 46.7% of those assigned tai chi chih achieved treatment response. Tai chi chih was noninferior to cognitive behavioral therapy at 3 months (P = .02), 6 months (P < .01) and 15 months (P = .02).

A higher percentage of individuals assigned cognitive behavioral therapy achieved insomnia remission (46.2% vs. 37.9%). Survivors in both groups achieved similar “robust improvements” in sleep quality, sleep diary measures and related symptoms (P < .01 for all), researchers wrote.

HemOnc Today spoke with Irwin about the study results and their implications, as well as the potential benefits of tai chi chih or similar practices may have for cancer survivors or individuals undergoing active treatment.

 

Question: What prompted this research?

Answer: Cancer survivors — particularly breast cancer survivors — have a greater rate of insomnia than the general population. Survivors who are many years out from treatment continue to have high rates of insomnia. The second rationale concerned the need to evaluate the efficacy of accessible and community-based approaches, such as tai chi, for the treatment of insomnia. Cognitive behavioral therapy is highly effective for treatment of insomnia, with efficacy and durability comparable to pharmacotherapy but without side effects from the medications. Unfortunately, cognitive therapy for insomnia is not widely used in medical and especially oncology settings. This is partly because cognitive behavioral therapy for insomnia is expensive. It requires trained professionals to administer, which limits accessibility. This is particularly so for cancer survivors, who are being seen by oncologists who may not be familiar with cognitive behavioral therapy.

 

Q: How did you conduct the study?

A: We wanted to evaluate the efficacy of a community-based approach — tai chi chih, a westernized version of tai chi — that could be easily implemented at a very low cost. Tai chi chih can improve sleep, but it is not known whether it is as effective and durable for the treatment of insomnia as cognitive therapy. We designed a trial that tested whether tai chi chih was noninferior to cognitive behavioral therapy for the treatment of insomnia among breast cancer survivors. Both treatments were delivered during a 12-week period to breast cancer survivors who were 6 months posttreatment. Investigators evaluated insomnia clinical response and insomnia remission after treatment. Follow-up was 1 year.

 

Q: What did you find?

A: Both interventions induced robust rates of insomnia treatment response as indicated by marked clinical improvement — or complete or nearly complete remission — of insomnia symptoms that were comparable to reported treatment response for cognitive behavioral therapy for insomnia among adult cancer survivors of cancer. Further, tai chi chih was noninferior to cognitive behavioral therapy for insomnia. Both cognitive behavioral therapy for insomnia and tai chi chih appeared associated with equivalent rates of insomnia treatment response that were durably maintained during follow-up.

Importantly, the long-term benefits of tai chi chih were due to the fact that breast cancer survivors continued to engage in daily practice of tai chi chih, indicating a high level of acceptability and adherence to this community-based treatment. Possibly, the breast cancer survivor cohort were so committed to the practice because they knew that insomnia lowered their quality of life. Additionally, there is evidence that insomnia increases their risk for breast cancer recurrence. Secondary outcomes demonstrated that tai chi chih was noninferior to cognitive behavioral therapy with similar improvements in sleep quality, which was robust. On average, they fell below the clinical threshold of severe insomnia. Moreover, both treatment groups showed robust and similar improvements in depressive symptoms and fatigue. These are symptoms that are often neglected in trials, but they lead to insomnia.

 

Q: What are the potential clinical implications of the findings?

A: The most striking clinical implication is that a community-accessible, inexpensive, self-administered intervention such as tai chi chih significantly improves insomnia, with an efficacy comparable to the gold standard for insomnia treatment.

 

Q: What are the potential benefits of tai chi chih and similar practices for patients with cancer and cancer survivors?

A: We previously found that people who practice tai chi chih achieve decreases in their perceived experiences of stress, as measured by both psychological and physiological responses. For example, the practice of tai chi chih reduces levels of perceived stress, anxiety and depression, which are related to decreases in blood pressure and inflammation — two risk factors for cardiovascular disease. In other words, when someone practices tai chi chih, their sleep may benefit, but they may also experience improvements in psychological and physiological markers of stress. Such decreases in inflammation following the practice of tai chi chih have been found among older adults, as well as breast cancer survivors.

 

Q: Is there anything else that you would like to mention?

A: Tai chi chih is one of several mind-body treatments — others being meditation and yoga that we have found to improve sleep, anxiety and depressive symptoms. Moreover, these mind-body approaches target stress response pathways, and they drive changes at the systemic, cellular and molecular levels, which impact health outcomes. Given the robust effects of tai chi chih — as well as meditation — to improve clinical insomnia, further work is identifying the molecular mechanisms underlying the benefits of these mind-body treatments. This can guide the development and delivery of interventions with greater psychological and biological precision to promote well-being among cancer survivors. – by Jennifer Southall

 

Reference:

Irwin MR, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2016.71.0285.

 

For more information:

Michael R. Irwin, MD, can be reached at David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., #12138, Los Angeles, CA 90095; email: michaelirwin1@mac.com.

 

Disclosure: Irwin reports no relevant financial disclosures.

Michael R. Irwin

Tai chi chih appeared statistically noninferior to cognitive behavioral therapy for the long-term treatment of insomnia among breast cancer survivors, according to study results.

“Given that standardized tai chi chih is both scalable and community accessible compared with the limited availability of cognitive behavioral therapy in most medical centers, immediate access to tai chi chih would address the need to reduce the morbidity associated with insomnia in survivors of breast and other cancers with treatment benets commensurate with the status quo of clinical treatment approaches to insomnia,” Michael R. Irwin, MD, Cousins distinguished professor of psychiatry and biobehavioral sciences at David Geffen School of Medicine at UCLA, and colleagues wrote.

Irwin and colleagues conducted a randomized, partially blinded noninferiority trial that included 90 breast cancer survivors with comorbid insomnia. Researchers randomly assigned individuals to tai chi chih (n = 45) or cognitive behavioral therapy (n=45).

Outcome measures included insomnia treatment response, insomnia remission, sleep and behavior.

At 15 months, 43.7% of those assigned cognitive behavioral therapy and 46.7% of those assigned tai chi chih achieved treatment response. Tai chi chih was noninferior to cognitive behavioral therapy at 3 months (P = .02), 6 months (P < .01) and 15 months (P = .02).

A higher percentage of individuals assigned cognitive behavioral therapy achieved insomnia remission (46.2% vs. 37.9%). Survivors in both groups achieved similar “robust improvements” in sleep quality, sleep diary measures and related symptoms (P < .01 for all), researchers wrote.

HemOnc Today spoke with Irwin about the study results and their implications, as well as the potential benefits of tai chi chih or similar practices may have for cancer survivors or individuals undergoing active treatment.

 

Question: What prompted this research?

Answer: Cancer survivors — particularly breast cancer survivors — have a greater rate of insomnia than the general population. Survivors who are many years out from treatment continue to have high rates of insomnia. The second rationale concerned the need to evaluate the efficacy of accessible and community-based approaches, such as tai chi, for the treatment of insomnia. Cognitive behavioral therapy is highly effective for treatment of insomnia, with efficacy and durability comparable to pharmacotherapy but without side effects from the medications. Unfortunately, cognitive therapy for insomnia is not widely used in medical and especially oncology settings. This is partly because cognitive behavioral therapy for insomnia is expensive. It requires trained professionals to administer, which limits accessibility. This is particularly so for cancer survivors, who are being seen by oncologists who may not be familiar with cognitive behavioral therapy.

PAGE BREAK

 

Q: How did you conduct the study?

A: We wanted to evaluate the efficacy of a community-based approach — tai chi chih, a westernized version of tai chi — that could be easily implemented at a very low cost. Tai chi chih can improve sleep, but it is not known whether it is as effective and durable for the treatment of insomnia as cognitive therapy. We designed a trial that tested whether tai chi chih was noninferior to cognitive behavioral therapy for the treatment of insomnia among breast cancer survivors. Both treatments were delivered during a 12-week period to breast cancer survivors who were 6 months posttreatment. Investigators evaluated insomnia clinical response and insomnia remission after treatment. Follow-up was 1 year.

 

Q: What did you find?

A: Both interventions induced robust rates of insomnia treatment response as indicated by marked clinical improvement — or complete or nearly complete remission — of insomnia symptoms that were comparable to reported treatment response for cognitive behavioral therapy for insomnia among adult cancer survivors of cancer. Further, tai chi chih was noninferior to cognitive behavioral therapy for insomnia. Both cognitive behavioral therapy for insomnia and tai chi chih appeared associated with equivalent rates of insomnia treatment response that were durably maintained during follow-up.

Importantly, the long-term benefits of tai chi chih were due to the fact that breast cancer survivors continued to engage in daily practice of tai chi chih, indicating a high level of acceptability and adherence to this community-based treatment. Possibly, the breast cancer survivor cohort were so committed to the practice because they knew that insomnia lowered their quality of life. Additionally, there is evidence that insomnia increases their risk for breast cancer recurrence. Secondary outcomes demonstrated that tai chi chih was noninferior to cognitive behavioral therapy with similar improvements in sleep quality, which was robust. On average, they fell below the clinical threshold of severe insomnia. Moreover, both treatment groups showed robust and similar improvements in depressive symptoms and fatigue. These are symptoms that are often neglected in trials, but they lead to insomnia.

 

Q: What are the potential clinical implications of the findings?

A: The most striking clinical implication is that a community-accessible, inexpensive, self-administered intervention such as tai chi chih significantly improves insomnia, with an efficacy comparable to the gold standard for insomnia treatment.

PAGE BREAK

 

Q: What are the potential benefits of tai chi chih and similar practices for patients with cancer and cancer survivors?

A: We previously found that people who practice tai chi chih achieve decreases in their perceived experiences of stress, as measured by both psychological and physiological responses. For example, the practice of tai chi chih reduces levels of perceived stress, anxiety and depression, which are related to decreases in blood pressure and inflammation — two risk factors for cardiovascular disease. In other words, when someone practices tai chi chih, their sleep may benefit, but they may also experience improvements in psychological and physiological markers of stress. Such decreases in inflammation following the practice of tai chi chih have been found among older adults, as well as breast cancer survivors.

 

Q: Is there anything else that you would like to mention?

A: Tai chi chih is one of several mind-body treatments — others being meditation and yoga that we have found to improve sleep, anxiety and depressive symptoms. Moreover, these mind-body approaches target stress response pathways, and they drive changes at the systemic, cellular and molecular levels, which impact health outcomes. Given the robust effects of tai chi chih — as well as meditation — to improve clinical insomnia, further work is identifying the molecular mechanisms underlying the benefits of these mind-body treatments. This can guide the development and delivery of interventions with greater psychological and biological precision to promote well-being among cancer survivors. – by Jennifer Southall

 

Reference:

Irwin MR, et al. J Clin Oncol. 2017;doi:10.1200/JCO.2016.71.0285.

 

For more information:

Michael R. Irwin, MD, can be reached at David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., #12138, Los Angeles, CA 90095; email: michaelirwin1@mac.com.

 

Disclosure: Irwin reports no relevant financial disclosures.