Insomnia can be a difficult disorder facing many survivors of cancer, but limited access hampers the behavioral therapy that can effectively address insomnia. Stepped care delivery models can improve accessibility and enable adjusting for intensity of treatment to improve efficacy, according to results from a study published in Cancer.

Researchers assessed 51 cancer survivors with a mean age of 55 years and an elevated Insomnia Index Score (ISI) of at least 12. The ISI comprises 7 questions, with low scores indicating no insomnia and the highest scores (22-28) indicating severe clinical insomnia.

These identified patients underwent Sleep Training Education Program 1 (STEP-1). The entry level in this stepped-care approach consists of a single session on sleep education that lasts an hour. Delivered by a clinical psychologist, STEP-1 focuses on psychological education about insomnia in cancer survivors, an introduction to concepts around proper sleep hygiene, identification of 2 to 3 of the most pertinent principles of sleep hygiene for each patient, and development of a behavioral change plan to consistently apply over the subsequent month.

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After 1 month of STEP-1, ISI scores improved from a baseline mean of 17.1 to 11.2 (P <.001). Nearly half of all patients (45%) responded, with 41% of patients experiencing remission of their insomnia. Remission was defined as an ISI of less than 12, and treatment response was defined as an improvement of ISI score of 6 points or more. Notably, experiencing remission of insomnia in STEP-1 associated with lower severity of insomnia and a briefer duration of disordered sleeping at baseline.

The 59% of survivors (30 patients) with continued insomnia after 1 month on STEP-1 participated in a more intensive intervention called STEP-2. STEP-2 was a 3-session, group-based intervention based on cognitive behavioral therapy.

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Mean ISI in the patients entering STEP-2 was 16.9, improving to a mean of 8.8 after the intervention (P <.001). Most of these patients (79%) responded to STEP-2, and 71% of these patients experienced remission of their insomnia.

Mood, as assessed by the Profile of Mood States-Short Form, improved after both STEP-1 and STEP-2 (P <.001).

“Our efforts here seek to balance the desire for every patient with insomnia to receive the full course of the gold standard treatment, with the reality of survivorship care at most cancer centers which are appropriately focused primarily on delivering cancer treatment,” noted the authors.


Zhou ES, Michaud AL, Recklitis CJ. Developing efficient and effective behavioral treatment for insomnia in cancer survivors: results of a stepped care trial [published September 24, 2019]. Cancer. doi: 10.1002/cncr.32509