Cognitive Behavioral Therapy-Insomnia Demonstrates Effectiveness in Improving Cancer-Related Fatigue

Sheila Garland, PhD

In a recently published trial of cancer survivors, results from a secondary analysis showed that use of cognitive behavioral therapy for insomnia (CBT-I) was effective in treating cancer-related fatigue (CRF) while controlling for the common comorbidities of insomnia, perceived cognitive impairment (PCI), depression, and anxiety. Overall, these data point to the therapeutic potential of CBT-I as an intervention for improving CRF among cancer survivors with insomnia and PCI.¹

CBT-I is a multicomponent psychotherapy consisting of (1) sleep restriction, (2) stimulus control, (3) cognitive restructuring, (4) relaxation training, and (5) sleep hygiene. The cohort, which featured mainly patients with breast cancer (41%), randomly assigned 132 patients to either immediate (n = 63) or sleep-self monitoring waitlist control group (n = 69). Fatigue, measured using the Multidimensional Fatigue Symptom Inventory – Short Form at pre-, mid-, and post-treatment, showed significant improvement with a reduction of more than 10.79 points.

Led by Sheila Garland, PhD, an associate professor at Memorial University, the linear mixed-effects model showed a significant group-by-time interaction on CFR, where the treatment group reported a 20.6-point reduction in fatigue compared with a 3.7-point reduction in the waitlist control with a large effect size (Cohen’s d = .937; P <.001). For context, there were no significant difference in CRF at baseline between the treatment group (M = 29.57) and sleep-self monitoring waitlist control group (M = 30.21),t(129) = .21; P = .833).

Coming into the study, the participants were mainly White (92.4%) and women (77%), with an average age of 60.12 years (SD, 11.37). In the trial, those treated with CBT-I demonstrated an overall reduction nearly twice the clinically significant threshold of at least 10.79 points on the MFSI. Individually, 77% of participants (n = 44) in the treatment group reported significant improvement in CRF, with a decrease of 10.79 points or more, compared with 27% (n = 18) in the control group.

READ MORE: Meta-Analysis Confirms Efficacy of Sodium Oxybate in Managing Narcolepsy Symptoms

"The previously published primary outcome of this trial found that CBT-I significantly improved cancer-related cognitive impairments,” Garland et al wrote.¹ "Moreover, depression and anxiety have also been reported to improve after CBT-I. Therefore, the present study along with the existing literature suggest that improving insomnia through CBT-I can also improve other comorbid symptoms in cancer survivors."

"The reason for this may be due to the close relation of insomnia to CRF, depression, anxiety, and cognitive impairment, where improving sleep may improve these symptoms as well. These comorbidities may share similar underlying mechanisms, such as an increase of proinflammatory cytokines, and dysregulation of the HPA axis and autonomic nervous system, as well as behavioral mechanisms. Therefore, it is possible that the improvement of sleep through CBT-I allows for improvement of symptoms with a related etiology," the study authors wrote.

Additional data revealed that CBT-I significantly reduced CRF (c=14.01; 95% CI, 10.51–17.51), primarily mediated by improvements in insomnia (ab=6.33; 95% CI, 2.85–10.22) and depression symptoms (ab=4.39; 95% CI, 2.20–6.84). Additional effects were mediated by changes in perceived cognitive impairment (ab=2.33; 95% CI, 0.19–4.66) and anxiety symptoms (ab=1.52; 95% CI, 0.11–3.05). Insomnia improvements accounted for nearly half of the overall effect.

The previously published primary outcome of this trial found that CBT-I significantly improved cancer-related cognitive impairments. Published in the Journal of Clinical Oncology in early 2024, those on CBT-I treatment reported an 11.35-point reduction in insomnia severity, compared with a 2.67-poiny reductio in the waitlist control group (P <.001). The treatment group had a greater overall improvement than the waitlist control on PCI (P <.001; d = .75), cognitive abilities (P <.001; d = .92), and impact on quality of life (P <.001; d = 1.01).²

REFERENCE
1. Greenley KM, Rash J, Tulk J, et al. Impact and Mechanisms of Cognitive Behavioural Therapy for Insomnia on Fatigue among Cancer Survivors: A Secondary Analysis of a Randomized Controlled Trial. Sleep. Published online January 18, 2025. doi:10.1093/sleep/zsaf014
2. Garland SN, Tulk J, Savard J, et al. Randomized Controlled Trial of Virtually Delivered Cognitive Behavioral Therapy for Insomnia to Address Perceived Cancer-Related Cognitive Impairment in Cancer Survivors. Journal of Clin Onc. 2024;42(17). doi:10.1200/JCO.23.02330