Providing access to cognitive-behavioral therapy for insomnia in cancer care: Preliminary results of an implementation study.
Authors: Savard Josée , Godin Émilie , Caplette-Gingras Aude , Morin Charles M. , Bélanger Lynda , Gagnon Marie-Pierre , Lamontagne Marie-Ève 
Published: September 2024

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Background:
Between 30 to 60% of cancer patients display insomnia symptoms. While cognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, it remains underutilized due to its limited accessibility. To date, we are unaware of any study that has investigated the implementation of CBT-I in routine clinical care. Our prior work showed that a stepped care approach, combining a web-based CBT-I and 1-3 booster therapy sessions, was not significantly inferior in producing sleep improvements than a standard 6-session CBT-I. The main goals of the IMPACT (Insomnia in Patients with Cancer – Personalized Treatment) program are to assess the feasibility and efficacy of implementing this stepped care CBT-I in four cancer centers in Quebec City, Canada.
Methods:
The ongoing study uses a stepped wedge cluster non-randomized design implementing the stepped care CBT-I at various time intervals across cancer centers. All first-line cancer providers (e.g., nurses, oncologists, radio-oncology technologists, pharmacists) are met every 3-4 months to present/remind them of the rationale of the project and procedures to refer patients to the IMPACT program. Patients having a score ≥ 4 on the sleep item of the Edmonton System Assessment System-Revised (ESAS-R-sleep) receive a leaflet explaining the stepped care CBT-I and how to access the web-based program (first step). Patients with residual insomnia symptoms after completing this first step are offered 1-3 booster sessions with a clinical psychologist (second step). Uptake and retention rates are the main variables.
Results:
Across cancer centers, 11.9%-50.8% of patients having a score ≥ 4 on the ESAS-R-sleep item were referred to the IMPACT program. The most common reasons for not referring were: 1) the presence of comorbid anxiety or depression symptoms (they were referred instead to the psychosocial oncology team) and; 2) patients declining help. Registration rates were greater when a brief follow-up phone call was conducted to explain the IMPACT program in more detail (vs. giving only the leaflet). Across cancer centers, 10%-54.9% of referred patients registered with the web-based CBT-I, 83.3%-90% of them initiated it and 26%-42.3% completed it. The most common reasons for not completing the web-based CBT-I were: 1) sleep difficulties improved or remitted (36.2%); and 2) the program did not meet patients’ needs (23.4%). Among completers, 29%-56% had residual insomnia and were offered booster sessions. On average, sleep diary data collected during treatment (N=83) indicated a reduction of sleep-onset latency of 20 min and of wake after sleep onset of 45 min. Sleep efficiency increased from 70 to 85%.
Conclusions:
Although uptake and retention rates could be improved, these preliminary data suggest that stepped care CBT-I can be implemented in routine cancer care and is effective.

Clinical trial information:
NCT04817163

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