International Journal of Behavioral Medicine

, Volume 25, Issue 5, pp 502–516 | Cite as

Sleepless from the Get Go: Sleep Problems Prior to Initiating Cancer Treatment

  • Eric S. ZhouEmail author
  • Karen Clark
  • Christopher J. Recklitis
  • Richard Obenchain
  • Matthew Loscalzo



Cancer patients are likely to experience sleep problems. Understanding their perception of sleep problems is important as subjective symptom experience is associated with treatment-seeking behavior. We explored the prevalence of sleep problems and its correlates in a large sample of cancer patients at an important but understudied stage of their cancer journey: prior to initiating treatment.


Cancer patients (5702) (67.5% female; 76.9% White; 23.0% Hispanic), following diagnosis and prior to initiating cancer treatment, completed an electronic screening instrument. Patients across eight different cancer diagnoses (breast, gastrointestinal, gynecological, head and neck, hematological, lung, prostate, urinary) rated their sleep problems on a five-point scale, with those reporting “severe” or “very severe” sleep problems classified as having high sleep problems.


Overall, 12.5% of patients reported high sleep problems. Across diagnoses, the proportion of patients reporting high sleep problems ranged from 4.3 to 13.8%, with prostate cancer patients least likely and gastrointestinal cancer patients most likely to report high sleep problems. Older age, having a partner, higher education, and higher household income were associated with a lower likelihood of experiencing sleep problems. Being female, Black, Hispanic, and reporting anxiety or depression was associated with an increased likelihood of sleep problems.


A sizeable proportion of cancer patients experience significant problems with their sleep before any treatment has occurred. This clinical issue cannot be ignored as treatment is likely to worsen existing sleep problems. Oncology providers should routinely screen for sleep-related problems. Identifying and treating patients for sleep problems during a vulnerable period early in their cancer trajectory should be an essential component of clinical care.


Sleep problems Sleep dysfunction Sleep disturbances Cancer patient Oncology 



This research was supported by internal funding at the City of Hope Comprehensive Cancer Center.

Compliance with Ethical Standards

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

Conflict of Interest

The authors declare that they have no conflict of interest.

Financial Disclosures

SupportScreen is a licensed product of the City of Hope.


  1. 1.
    Linden W, Vodermaier A, Mackenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. J Affect Disord. 2012;141(2–3):343–51. Scholar
  2. 2.
    van't Spijker A, Trijsburg RW, Duivenvoorden HJ. Psychological sequelae of cancer diagnosis: a meta-analytical review of 58 studies after 1980. Psychosom Med. 1997;59(3):280–93.CrossRefGoogle Scholar
  3. 3.
    Carter BJ. Long-term survivors of breast cancer. A qualitative descriptive study. Cancer Nurs. 1993;16(5):354–61.CrossRefGoogle Scholar
  4. 4.
    Cimprich B. Pretreatment symptom distress in women newly diagnosed with breast cancer. Cancer Nurs. 1999;22(3):185–94.CrossRefGoogle Scholar
  5. 5.
    Dickerson SS, Alqaissi N, Underhill M, Lally RM. Surviving the wait: defining support while awaiting breast cancer surgery. J Adv Nurs. 2011;67(7):1468–79.CrossRefGoogle Scholar
  6. 6.
    Foley DJ, Monjan AA, Brown SL, Simonsick EM, Wallace RB, Blazer DG. Sleep complaints among elderly persons: an epidemiologic study of three communities. Sleep. 1995;18(6):425–32.CrossRefGoogle Scholar
  7. 7.
    Arber S, Bote M, Meadows R. Gender and socio-economic patterning of self-reported sleep problems in Britain. Soc Sci Med. 2009;68(2):281–9.CrossRefGoogle Scholar
  8. 8.
    Patel NP, Grandner MA, Xie D, Branas CC, Gooneratne N. “Sleep disparity” in the population: poor sleep quality is strongly associated with poverty and ethnicity. BMC Public Health. 2010;10:475.CrossRefGoogle Scholar
  9. 9.
    Grandner MA, Patel NP, Gehrman PR, Xie D, Sha D, Weaver T, et al. Who gets the best sleep? Ethnic and socioeconomic factors related to sleep complaints. Sleep Med. 2010;11(5):470–8. Scholar
  10. 10.
    Jean-Louis G, Magai CM, Cohen CI, Zizi F, von Gizycki H, DiPalma J, et al. Ethnic differences in self-reported sleep problems in older adults. Sleep. 2001;24(8):926–33.CrossRefGoogle Scholar
  11. 11.
    Ruel S, Savard J, Ivers H. Insomnia and self-reported infections in cancer patients: an 18-month longitudinal study. Health Psychol. 2015;34(10):983–91. Scholar
  12. 12.
    Stepanski EJ, Walker MS, Schwartzberg LS, Blakely LJ, Ong JC, Houts AC. The relation of trouble sleeping, depressed mood, pain, and fatigue in patients with cancer. J Clin Sleep Med. 2009;5(2):132–6.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Irwin MR. Depression and insomnia in cancer: prevalence, risk factors, and effects on cancer outcomes. Curr Psychiatry Rep. 2013;15(11):404. Scholar
  14. 14.
    Zhou ES, Recklitis CJ. Insomnia in adult survivors of childhood cancer: a report from project reach. Support Care Cancer. 2014;22(11):3061–9. Scholar
  15. 15.
    Trudel-Fitzgerald C, Zhou ES, Poole EM, Zhang X, Michels KB, Eliassen AH, et al. Sleep and survival among women with breast cancer: 30 years of follow-up within the nurses’ health study. Br J Cancer. 2017;116:1239–46.CrossRefGoogle Scholar
  16. 16.
    Irwin DE, Milsom I, Kopp Z, Abrams P, Group ES. Symptom bother and health care–seeking behavior among individuals with overactive bladder. Eur Urol. 2008;53(5):1029–39.CrossRefGoogle Scholar
  17. 17.
    Savard J, Morin CM. Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol. 2001;19(3):895–908. Scholar
  18. 18.
    Dahiya S, Ahluwalia MS, Walia HK. Sleep disturbances in cancer patients: underrecognized and undertreated. Cleve Clin J Med. 2013;80(11):722–32. Scholar
  19. 19.
    Zhou ES, Partridge AH, Syrjala KL, Michaud AL, Recklitis CJ. Evaluation and treatment of insomnia in adult cancer survivorship programs. J Cancer Surviv. 2017;11(1):74–9. Scholar
  20. 20.
    Garland SN, Johnson JA, Savard J, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113–24. Scholar
  21. 21.
    Chen ML, Yu CT, Yang CH. Sleep disturbances and quality of life in lung cancer patients undergoing chemotherapy. Lung Cancer. 2008;62(3):391–400. Scholar
  22. 22.
    Dean GE, Abu Sabbah E, Yingrengreung S, Ziegler P, Chen H, Steinbrenner LM, et al. Sleeping with the enemy: sleep and quality of life in patients with lung cancer. Cancer Nurs. 2015;38(1):60–70. Scholar
  23. 23.
    Yu S-Y, Nho J-H. Influence of sleep disturbance and depression on quality of life in ovarian cancer patients during chemotherapy. Asian Oncol Nurs. 2015;15(4):203–10.CrossRefGoogle Scholar
  24. 24.
    Redeker NS, Lev EL, Ruggiero J. Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy. Sch Inq Nurs Pract. 2000;14(4):275–90. discussion 91-8PubMedGoogle Scholar
  25. 25.
    Palesh OG, Roscoe JA, Mustian KM, Roth T, Savard J, Ancoli-Israel S, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester cancer center-community clinical oncology program. J Clin Oncol. 2010;28(2):292–8. Scholar
  26. 26.
    Zhou ES, Manley PE, Marcus KJ, Recklitis CJ. Medical and psychosocial correlates of insomnia symptoms in adult survivors of pediatric brain tumors. J Pediatr Psychol. 2016;41(6):623–30. Scholar
  27. 27.
    Gooneratne NS, Dean GE, Rogers AE, Nkwuo JE, Coyne JC, Kaiser LR. Sleep and quality of life in long-term lung cancer survivors. Lung Cancer. 2007;58(3):403–10. Scholar
  28. 28.
    Otte JL, Carpenter JS, Russell KM, Bigatti S, Champion VL. Prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors. J Pain Symptom Manag. 2010;39(3):535–47. Scholar
  29. 29.
    Otte JL, Carpenter JS, Manchanda S, Rand KL, Skaar TC, Weaver M, et al. Systematic review of sleep disorders in cancer patients: can the prevalence of sleep disorders be ascertained? Cancer Med. 2015;4(2):183–200. Scholar
  30. 30.
    Savard J, Ivers H, Villa J, Caplette-Gingras A, Morin CM. Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. J Clin Oncol. 2011;29(26):3580–6. Scholar
  31. 31.
    Davidson JR, MacLean AW, Brundage MD, Schulze K. Sleep disturbance in cancer patients. Soc Sci Med. 2002;54(9):1309–21.CrossRefGoogle Scholar
  32. 32.
    Loscalzo M, Clark K, Dillehunt J, Rinehart R, Strowbridge R, Smith D. SupportScreen: a model for improving patient outcomes. J Natl Compr Cancer Netw. 2010;8(4):496–504.CrossRefGoogle Scholar
  33. 33.
    Zabora JR, Loscalzo MJ, Weber J, editors. Managing complications in cancer: identifying and responding to the patient’s perspective. Semin Oncol Nurs. 2003;19(2):1–9.Google Scholar
  34. 34.
    Loscalzo MJ, Clark KL. Problem-related distress in cancer patients drives requests for help: a prospective study. Oncology. 2007;21(9):1133–8.PubMedGoogle Scholar
  35. 35.
    Clark K, Bardwell WA, Arsenault T, DeTeresa R, Loscalzo M. Implementing touch-screen technology to enhance recognition of distress. Psychooncology. 2009;18(8):822–30. Scholar
  36. 36.
    Lowery AE, Greenberg MA, Foster SL, Clark K, Casden DR, Loscalzo M, et al. Validation of a needs-based biopsychosocial distress instrument for cancer patients. Psychooncology. 2012;21(10):1099–106. Scholar
  37. 37.
    Miller MF, Buzaglo JS, Clark KL, Loscalzo MJ, Kennedy V, Taylor J, et al. Demonstrating the psychometric properties of a problem-related distress screener in a community sample of 319 cancer survivors. Psychooncology. 2013;22(6):1249–57. Scholar
  38. 38.
    Zhou ES, Partridge AH, Recklitis CJ. A pilot trial of brief group cognitive-behavioral treatment for insomnia in an adult cancer survivorship program. Psychooncology. 2017;26(6):843–8. Scholar
  39. 39.
    Savard J, Savard M-H. Insomnia and cancer: prevalence, nature, and nonpharmacologic treatment. Sleep Med Clin. 2013;8(3):373–87.CrossRefGoogle Scholar
  40. 40.
    Morin CM, LeBlanc M, Daley M, Gregoire JP, Merette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006;7(2):123–30. Scholar
  41. 41.
    Ohayon MM, Caulet M, Priest RG, Guilleminault C. DSM-IV and ICSD-90 insomnia symptoms and sleep dissatisfaction. Br J Psychiatry. 1997;171(4):382–8.CrossRefGoogle Scholar
  42. 42.
    Zhang B, Wing YK. Sex differences in insomnia: a meta-analysis. Sleep. 2006;29(1):85–93.CrossRefGoogle Scholar
  43. 43.
    McLean CP, Asnaani A, Litz BT, Hofmann SG. Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res. 2011;45(8):1027–35. Scholar
  44. 44.
    Kuehner C. Gender differences in unipolar depression: an update of epidemiological findings and possible explanations. Acta Psychiatr Scand. 2003;108(3):163–74.CrossRefGoogle Scholar
  45. 45.
    Barsky AJ, Peekna HM, Borus JF. Somatic symptom reporting in women and men. J Gen Intern Med. 2001;16(4):266–75.CrossRefGoogle Scholar
  46. 46.
    Khan AA, Gardner CO, Prescott CA, Kendler KS. Gender differences in the symptoms of major depression in opposite-sex dizygotic twin pairs. Am J Psychiatry. 2002;159(8):1427–9. Scholar
  47. 47.
    Johnson EO, Roth T, Breslau N. The association of insomnia with anxiety disorders and depression: exploration of the direction of risk. J Psychiatr Res. 2006;40(8):700–8. Scholar
  48. 48.
    Taylor DJ, Lichstein KL, Durrence HH, Reidel BW, Bush AJ. Epidemiology of insomnia, depression, and anxiety. Sleep. 2005;28(11):1457–64.CrossRefGoogle Scholar
  49. 49.
    Goodwin PJ, Ennis M, Pritchard KI, Trudeau M, Hood N. Risk of menopause during the first year after breast cancer diagnosis. J Clin Oncol. 1999;17(8):2365–70. Scholar
  50. 50.
    Savard J, Davidson JR, Ivers H, Quesnel C, Rioux D, Dupéré V, et al. The association between nocturnal hot flashes and sleep in breast cancer survivors. J Pain Symptom Manag. 2004;27(6):513–22.CrossRefGoogle Scholar
  51. 51.
    Durrence HH, Lichstein KL. The sleep of African Americans: a comparative review. Behav Sleep Med. 2006;4(1):29–44. Scholar
  52. 52.
    Ruiter ME, Decoster J, Jacobs L, Lichstein KL. Normal sleep in African-Americans and Caucasian-Americans: a meta-analysis. Sleep Med. 2011;12(3):209–14. Scholar
  53. 53.
    Mezick EJ, Matthews KA, Hall M, Strollo PJ Jr, Buysse DJ, Kamarck TW, et al. Influence of race and socioeconomic status on sleep: Pittsburgh sleepscore project. Psychosom Med. 2008;70(4):410–6. Scholar
  54. 54.
    Hall MH, Matthews KA, Kravitz HM, Gold EB, Buysse DJ, Bromberger JT, et al. Race and financial strain are independent correlates of sleep in midlife women: the SWAN sleep study. Sleep. 2009;32(1):73–82.PubMedPubMedCentralGoogle Scholar
  55. 55.
    Karacan I, Thornby JI, Anch M, Holzer CE, Warheit GJ, Schwab JJ, et al. Prevalence of sleep disturbance in a primarily urban Florida county. Soc Sci Med. 1976;10(5):239–44.CrossRefGoogle Scholar
  56. 56.
    Pigeon WR, Heffner K, Duberstein P, Fiscella K, Moynihan J, Chapman BP. Elevated sleep disturbance among blacks in an urban family medicine practice. J Am Board Fam Pract. 2011;24(2):161–8.CrossRefGoogle Scholar
  57. 57.
    Gold EB, Sternfeld B, Kelsey JL, Brown C, Mouton C, Reame N, et al. Relation of demographic and lifestyle factors to symptoms in a multi-racial/ethnic population of women 40-55 years of age. Am J Epidemiol. 2000;152(5):463–73.CrossRefGoogle Scholar
  58. 58.
    Chen X, Wang R, Zee P, Lutsey PL, Javaheri S, Alcántara C, et al. Racial/ethnic differences in sleep disturbances: the multi-ethnic study of atherosclerosis (MESA). Sleep. 2015;38(6):877–88. Scholar
  59. 59.
    Loredo JS, Soler X, Bardwell W, Ancoli-Israel S, Dimsdale JE, Palinkas LA. Sleep health in US Hispanic population. Sleep. 2010;33(7):962–7.CrossRefGoogle Scholar
  60. 60.
    Morphy H, Dunn KM, Lewis M, Boardman HF, Croft PR. Epidemiology of insomnia: a longitudinal study in a UK population. Sleep. 2007;30(3):274–80.PubMedGoogle Scholar
  61. 61.
    Ohayon MM, Smirne S. Prevalence and consequences of insomnia disorders in the general population of Italy. Sleep Med. 2002;3(2):115–20.CrossRefGoogle Scholar
  62. 62.
    Hohagen F, Kappler C, Schramm E, Riemann D, Weyerer S, Berger M. Sleep onset insomnia, sleep maintaining insomnia and insomnia with early morning awakening—temporal stability of subtypes in a longitudinal study on general practice attenders. Sleep. 1994;17(6):551–4.PubMedGoogle Scholar
  63. 63.
    Lavie P. Sleep habits and sleep disturbances in industrial workers in Israel: main findings and some characteristics of workers complaining of excessive daytime sleepiness. Sleep. 1980;4(2):147–58.CrossRefGoogle Scholar
  64. 64.
    Leger D, Guilleminault C, Dreyfus JP, Delahaye C, Paillard M. Prevalence of insomnia in a survey of 12,778 adults in France. J Sleep Res. 2000;9(1):35–42.CrossRefGoogle Scholar
  65. 65.
    Hall M, Buysse DJ, Nowell PD, Nofzinger EA, Houck P, Reynolds CF III, et al. Symptoms of stress and depression as correlates of sleep in primary insomnia. Psychosom Med. 2000;62(2):227–30.CrossRefGoogle Scholar
  66. 66.
    Cho YW, Shin WC, Yun CH, Hong SB, Kim J, Earley CJ. Epidemiology of insomnia in korean adults: prevalence and associated factors. J Clin Neurol. 2009;5(1):20–3. Scholar
  67. 67.
    Gellis LA, Lichstein KL, Scarinci IC, Durrence HH, Taylor DJ, Bush AJ, et al. Socioeconomic status and insomnia. J Abnorm Psychol. 2005;114(1):111–8. Scholar
  68. 68.
    Cairney J, Arnold R. Social class, health and aging: socioeconomic determinants of self-reported morbidity among the noninstitutionalized elderly in Canada. Can J Public Health. 1995;87(3):199–203.Google Scholar
  69. 69.
    Sutton DA, Moldofsky H, Badley EM. Insomnia and health problems in Canadians. Sleep. 2001;24(6):665–70.CrossRefGoogle Scholar
  70. 70.
    Innominato PF, Spiegel D, Ulusakarya A, Giacchetti S, Bjarnason GA, Lévi F, et al. Subjective sleep and overall survival in chemotherapy-naïve patients with metastatic colorectal cancer. Sleep Med. 2015;16(3):391–8. Scholar
  71. 71.
    Johnson EO. Sleep in america: 1999. Results from the National Sleep. Foundations. 1999;Google Scholar
  72. 72.
    Morin CM, LeBlanc M, Belanger L, Ivers H, Merette C, Savard J. Prevalence of insomnia and its treatment in canada. Can J Psychiatr. 2011;56(9):540–8. Scholar
  73. 73.
    Brinkman TM, Zhang N, Recklitis CJ, Kimberg C, Zeltzer LK, Muriel AC, et al. Suicide ideation and associated mortality in adult survivors of childhood cancer. Cancer. 2013;120(2):271–7. Scholar
  74. 74.
    National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: survivorship. 2015.Google Scholar

Copyright information

© International Society of Behavioral Medicine 2018

Authors and Affiliations

  • Eric S. Zhou
    • 1
    • 2
    Email author
  • Karen Clark
    • 3
  • Christopher J. Recklitis
    • 1
    • 2
  • Richard Obenchain
    • 3
  • Matthew Loscalzo
    • 3
  1. 1.Perini Family Survivors’ CenterDana-Farber Cancer InstituteBostonUSA
  2. 2.PediatricsHarvard Medical SchoolBostonUSA
  3. 3.Supportive Care MedicineCity of Hope National Medical CenterDuarteUSA

Personalised recommendations