Sleep Disturbances in Childhood Cancer Survivors

Abstract

To the Editor: We read with interest Ruble and colleagues'[1] study examining sleep-disordered breathing (SDB) symptoms in childhood cancer survivors (CCS). CCS were 3.3 times more likely to be at risk of SDB than the general childhood population. SDB symptoms were strongly associated with stress, poor school performance, and poor quality-of-life (QOL) outcomes.These findings align with data collected from our ongoing study of more than 400 CCS, >5 years postcancer diagnosis and treated at Sydney Children's Hospital, Australia. In our study, parents of CCS age <16 years (n = 130; CCS mean = 12.41; SD = 2.2) completed proxy questionnaires measuring their children's sleep disturbances (SDis; difficulty falling asleep, waking up in the night or earlier than desired, and nonrefreshing sleep). Adult CCS, age >16 also completed the questionnaire (n = 263; mean = 27.57; SD = 8.05).Many parents reported that their child suffered from SDis (44.6%), which occurred more than twice a week for 50% of children with SDis. Parents reported that SDis caused distress or interfered with daily living (53.4%). Lower overall health and energy levels were evident in those with SDis than those with no sleeping problems (U = 1285.5, n 1 = 57, n 2 = 68, P = 0.001 [two-tailed]; U = 1483, n 1 = 58, n 2 = 70, P < 0.01 [two-tailed], respectively). In terms of QOL, CCS with SDis more often described feeling sad (U = 1652.5, n 1 = 58, n 2 = 70, P < 0.05 [two-tailed]), and not being able to do leisure activities in their free time (U = 1601, n 1 = 58, n 2 = 69, P < 0.05 [two-tailed], respectively). Moreover, parents of survivors experiencing SDis reported poorer academic performance (U = 1504.5, n 1 = 58, n 2 = 70, P < 0.01 [two-tailed]) and lower frequency of pleasant recreational time with friends (U = 1521.5, n 1 = 58, n 2 = 69, P = 0.01 [two-tailed]).CCS age >16 years also reported SDis (n = 263; 70.3%). Sixty-nine percent CCS experienced SDis more than twice a week, causing distress or interfering with daily living in 57.1%. CCS with SDis reported lower overall health in the previous month (U = 3775, n 1 = 182, n 2 = 77, P < 0.001 [two-tailed]) and were more likely to report signs of anxiety or depression (U = 2016.5, n 1 = 126, n 2 = 51, P < 0.001 [two-tailed]) than those not experiencing SDis. Self-rated overall health was particularly low in those experiencing SDis more than twice a week (U = 2016.5, n 1 = 126, n 2 = 51, P < 0.001 [two-tailed]).Echoing the results of Ruble et al. survivors' body mass index did not appear to be significantly correlated with SDis (r = −0.07, n.s.). A logistic regression model with age, gender, hospitalization, and health problems predicting CCS likelihood of experiencing SDis was statistically significant, χ 2 (8) = 19.263, P < 0.05, explaining 16.7% (Nagelkerke R 2 ) of variance, and correctly classifying 70.2% of cases. Females were two times more likely to experience SDis. Increasing age and more reported hospitalization and health issues were associated with an increased likelihood of SDis.Medical and ...

Reply To: Sleep Disturbances in Childhood Cancer Survivors

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To the Editor: We would like to thank Russo and colleagues for their letter supporting our findings on sleep disturbances in childhood cancer survivors. [1] The additional data they present on sleep disturbances other than sleep disordered breathing (the focus of our paper) illustrate the breadth of the problem in this population. Russo et al identify important findings that reinforce our concerns about the potential morbidity of sleep disturbances in this population.

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Neurodevelopmental Consequences of Pediatric Cancer and Its Treatment: The Role of Sleep

“…In addition, the excessive daytime sleepiness caused by this disease can negatively impact on the child's learning, behavior and school performance [75] and cause an alteration of the cerebral gray matter in the areas involved in learning and emotional functions [77]. Thus it is important to treat this pathology, often also found in children with oncological pathologies [12,78], in whom neurocognitive problems can arise both as a consequence of cancer or of its treatment, as previously described [17,18,31,32,34,35]. As mentioned above, both OSA and cancer can cause structural changes in the brain, especially in the earliest stages of the child's development [3,10,[29][30][31][32]77].…”

A call to action for expanded sleep research in pediatric oncology: A position paper on behalf of the International Psycho‐Oncology Society Pediatrics Special Interest Group

“…8,62 Survivors experiencing disrupted sleep report lower overall health and higher levels of anxiety and depression than do survivors without sleep disruption. 8 However, few studies describe the prevalence, predictors, and consequences of sleep disturbance among childhood cancer survivors. It is also unclear whether sleep disturbances change or resolve at different stages after treatment completion.…”

“…Clinical research in adult oncology connects sleep and circadian dysregulation with symptom burden, tumor progression, and cancer prognosis (see Supplemental File A Adult Oncology). Research testing these outcomes in pediatric oncology is currently limited to the association between sleep or circadian rhythms and fatigue, or their inclusion in symptom clusters in children on active treatment . There are no longitudinal studies evaluating the effect of sleep disturbances (symptoms of inadequate or unrefreshing sleep), clinical sleep disorders (eg, insomnia, OSA, narcolepsy, excessive daytime sleepiness), or circadian dysregulation on cancer outcomes, leaving large gaps in our understanding of how sleep may affect cancer prognosis or other health‐related outcomes.…”

“…Minimizing the long‐term effects of cancer treatment and promoting QoL, including improved sleep outcomes after treatment, have, therefore, become a priority. Studies show that 47% to 69% of adolescent and young adult cancer survivors report sleep disturbances such as prolonged sleep onset latency, poor sleep efficiency, early waking, inadequate total sleep time, and nonrefreshing sleep . Survivors experiencing disrupted sleep report lower overall health and higher levels of anxiety and depression than do survivors without sleep disruption .…”