October 11, 2019
4 min read

Program takes ‘stepped-care’ approach to curing cancer survivors of insomnia

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Eric S. Zhou, PhD
Eric S. Zhou

The importance of good sleep habits has been reinforced by research and become well-known among the general public. Insufficient sleep has been linked to everything from depression and forgetfulness to heart disease risk and reduced immune function.

The effects can be particularly impactful to cancer survivors, many of whom are still rebounding from aggressive treatments, heightened anxiety and disruptions to their usual schedules. According to researchers from Dana-Farber Cancer Institute, as many as 30% of cancer survivors live with chronic insomnia.

“There are a lot of issues people bring to the table before they are diagnosed with cancer. I would say that a good number of patients I see were already bad sleepers before their cancer diagnosis, but never were treated for it,” Eric S. Zhou, PhD, attending psychologist specializing in the department of psychosocial oncology and palliative care at Dana-Farber, said in an interview with HemOnc Today. “Then they get diagnosed with cancer and are thrown into the deep end — dealing with everything from the anxiety around diagnosis to not sleeping well in the hospital, recovering from surgery, fatigue from radiation therapy, steroids that keep them awake, and hormone therapy that causes hot flashes. When you fit it all together, it’s shocking that some people go through the experience without developing insomnia.”

Many cancer survivors continue to grapple with chronic insomnia for years after successful treatment. Zhou spoke to HemOnc Today about a stepped approach he and his colleagues developed to address this pervasive problem.

Question: What prompted you to investigate chronic insomnia among cancer survivors?

Answer: It was a marriage of opportunity and need. In graduate school and during my fellowship, I helped patients and survivors deal with quality-of-life issues. When I was on residency, I had the privilege of working with someone leading the field of behavioral sleep medicine, Donn Posner, PhD, CBSM. During my post-doctoral fellowship at Dana-Farber, I realized that there was a significant clinical need here, and that I had a skill that could possibly help them.

Q: What gave you the idea to develop a single-session sleep education class for cancer survivors?

A: Despite being in Boston, which I believe is one of the best places in the world to be if you are very sick, there are only a few behavior sleep medicine providers. There was such a need and I wanted to get this information out there. Unfortunately, access to these providers is an issue and it was about finding a way to develop something that people who aren’t specifically trained in sleep medicine could deliver.


Q : Why is there such a shortage of cognitive behaviorists who specialize in sleep?

A: There is a huge deficit in sleep training for physicians and for psychologists. Multiple studies have shown that in the United States and Canada, very few physicians and psychologists receive didactic training in sleep during medical/graduate school. For example, the average physician in the United States gets less than 5 hours of classroom education about sleep in medical school. For psychologists, the numbers aren’t any better!

Q: How does your program differ from cognitive behavioral therapy (CBT) for insomnia ?

A: CBT for insomnia, which is distinct from CBT for other conditions like depression, is typically delivered over six to eight sessions. The most significant components of CBT for insomnia are stimulus control and sleep restriction, but these can be challenging to implement for patients. We distilled the core components of the tips and strategies that are readily available online or in printed materials. For example, we found that a lot of patients with cancer are told by their oncologist, “You need to rest.” They listen to their doctors and may end up lying in bed for, say, 12 hours per day. That might be perfectly appropriate during certain phases, such as when you leave the hospital after surgery. Unfortunately, some patients keep this thought process going months and years later. As a result, we have patients who are in bed 12 hours a night, even though the average adult usually needs between 7 and 9 hours. So essentially, these patients may be spending several hours a night tossing and turning, teaching their minds and bodies to become frustrated with the whole notion of sleep.

The biggest difference between what we do and what a person might find online is that we explain why you should do these things. Online, it’s a one-liner, “don’t stay in bed too long if you are not sleeping,” whereas here, we’ll tell you, “We’re not doing this to make you feel worse. It’s about matching time in bed to the amount of sleep you need. We’re going to figure out how much you need and prepare a game plan for how you can do this in the next month.”

Q: How do you use a stepped approach in your program?

A: if someone fails the one-session program, we offered them a second step, which consolidates delivery of the CBT principles from the typical six to eight sessions to three sessions. With the second step, instead of a 40-some percent cure rate, we were curing closer to 80% of patients of their insomnia. If you complete both steps in our program and we haven’t fixed your insomnia, other issues likely are playing a role that warrant further discussion with an individual provider.

Q: You discussed many factors that could contribute to insomnia among cancer survivors. Does your program work regardless of the cause?

A: Absolutely. It’s very cause-agnostic. It doesn’t matter whether you developed insomnia because you were anxious or because of pain during treatment 5 years ago. What we address are the ongoing mistakes people making with their sleep — the things you do initially in response to your poor sleep that wind up making the insomnia last. For example, someone who is fatigued from radiation might spend a lot of time in the afternoon taking naps. After radiation, those afternoon naps make it so they can’t sleep at night. The cause isn’t the radiation anymore; it’s what they do in reaction to the radiation.

The biggest thing our program can achieve is to let survivors know that they shouldn’t just accept their insomnia, because we can fix it. They don’t need to suffer from it. – by Jennifer Byrne


Zhou ES, et al. Cancer. 2019;doi:10.1002/cncr.32509.

For more information:

Eric S. Zhou, PhD, can be reached at 450 Brookline Ave., Boston, MA 02215;email: eric.zhou@dfci.harvard.edu.

Disclosures: Zhou reports no relevant financial disclosures.