Epidemiology

Sleep and survival among women with breast cancer: 30 years of follow-up within the Nurses’ Health Study

  • British Journal of Cancer 116, 12391246 (25 April 2017)
  • doi:10.1038/bjc.2017.85
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Abstract

Background:

Breast cancer is a leading cause of cancer death in women. Sleep has been linked with mortality among cancer-free population; however, its association with survival among women with breast cancer is understudied.

Methods:

Breast cancer patients (N=3682) reported their average sleep duration post diagnosis. Subsamples also provided their pre-diagnosis sleep duration (n=1949) and post-diagnosis sleep difficulties (n=1353). Multivariate Cox models estimated hazard ratios (HR) and confidence intervals (CI) of all-cause, breast cancer, and non-breast cancer mortality.

Results:

At diagnosis, the mean age was 64.9 years and 91.7% were stage I or II. Women sleeping 9 h per night post diagnosis had a strong higher risk of all-cause (multivariate HRs: MV-HR=1.37, CI=1.10–1.71), breast cancer (MV-HR=1.46, CI=1.02–2.07), and non-breast cancer mortality (MV-HR=1.34, CI=1.01–1.79), compared to women sleeping 8 h per night. Increased sleep duration post diagnosis (vs unchanged) and regular sleep difficulties (vs rare/none) were associated with a strong elevated risk of all-cause mortality (MV-HRincreased duration=1.35, CI=1.04–1.74; MV-HRregular difficulties=1.49, CI=1.02–2.19) and a moderate greater risk of breast cancer and non-breast cancer mortality.

Conclusions:

Various facets of sleep were associated with higher all-cause mortality risk. If replicated, these findings support evaluation of breast cancer patients’ sleep duration and difficulties to identify those at risk for poorer outcomes.

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Change history

  • Corrected online 25 April 2017

References

  1. American Cancer Society (2016a) Cancer Facts & Figures 2016. American Cancer Society: Atlanta.

  2. American Cancer Society (2016b) Learn about Cancer: Breast Cancer. American Cancer Society.

  3. , , (2001) The relationship between fatigue and sleep in cancer patients: a review. Eur J Cancer Care (Engl) 10: 245–255.

  4. , , , , , , (2016) Origin, methods, and evolution of the three Nurses' Health Studies. Am J Public Health 106: 1573–1581.

  5. (2009) Melatonin, sleep disturbance and cancer risk. Sleep Med Rev 13: 257–264.

  6. , , , , , , , (2012) Adverse metabolic consequences in humans of prolonged sleep restriction combined with circadian disruption. Sci Transl Med 4: 129ra43.

  7. , , , (2010) Sleep duration and all-cause mortality: a systematic review and meta-analysis of prospective studies. Sleep 33: 585–592.

  8. , , , , , (2004) Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncol Nurs Forum 31: 591–5598.

  9. , , , (2015) Sleep and multisystem biological risk: a population-based study. PLoS One 10: e0118467.

  10. , , (2011) Global Cancer Facts & Figures. American Cancer Society: Atlanta. 1–52.

  11. , , , , , (2011) Prevalence and predictors of sleep difficulty in a national cohort of women with primary breast cancer three to four months postsurgery. J Pain Symptom Manage 42: 710–720.

  12. , , , , , , , , (2003) Healthy older adults' sleep predicts all-cause mortality at 4 to 19 years of follow-up. Psychosom Med 65: 63–73.

  13. , , , , , (2016) Sleep and cancer: synthesis of experimental data and meta-analyses of cancer incidence among some 1 500 000 study individuals in 13 countries. Chronobiol Int 33: 325–350.

  14. , , , (2015) Melatonin, sleep, and prostate cancer in elderly men: study, hypothesis development, and Icelandic options. Eur Urol 67: 195–197.

  15. , , , , (2015) Risk of cancer in patients with insomnia, parasomnia, and obstructive sleep apnea: a nationwide nested case-control study. J Cancer 6: 1140–1147.

  16. , , , , , , (2007) A prospective study of change in sleep duration: associations with mortality in the Whitehall II cohort. Sleep 30: 1659–1666.

  17. , (2006) Insomnia and its treatment in women with breast cancer. Sleep Med Rev 10: 419–429.

  18. , , , , , , , , , , , , (2011) Differences in sleep disturbance and fatigue between patients with breast and prostate cancer at the initiation of radiation therapy. J Pain Symptom Manage 42: 239–250.

  19. , , (2013) Self-reported sleep duration, sleep quality, and breast cancer risk in a population-based case-control study. Am J Epidemiol 177: 316–327.

  20. , (2007) Who are the long sleepers? Towards an understanding of the mortality relationship. Sleep Med Rev 11: 341–360.

  21. , , , , (2005) Physical activity and survival after breast cancer diagnosis. JAMA 293: 2479–2486.

  22. , , , , , (2013) Sleep duration and incidence of colorectal cancer in postmenopausal women. Br J Cancer 108: 213–221.

  23. , , , , (2002) Mortality associated with sleep duration and insomnia. Arch Gen Psychiatry 59: 131–136.

  24. , , , , , (2013) Sleep duration and all-cause mortality: a critical review of measurement and associations. Ann Epidemiol 23: 361–370.

  25. , , , , , , , , , , (2013) Postdiagnosis alcohol consumption and breast cancer prognosis in the after breast cancer pooling project. Cancer Epidemiol Biomarkers Prev 22: 32–41.

  26. , , (2010) Effects of sleep and circadian rhythm on the human immune system. Ann NY Acad Sci 1193: 48–59.

  27. , , , , , (2015) Night-shift work increases morbidity of breast cancer and all-cause mortality: a meta-analysis of 16 prospective cohort studies. Sleep Med 16: 1381–1387.

  28. , , , , (2014) Sleep duration and incidence of lung cancer in ageing men. BMC Public Health 14: 295.

  29. , (2012) An examination of distress, sleep, and fatigue in metastatic breast cancer patients. Psychooncology 21: 100–107.

  30. , , , , (2009) Cardiovascular, inflammatory, and metabolic consequences of sleep deprivation. Prog Cardiovasc Dis 51: 294–302.

  31. , , , , , (2013) Sleep disruption in breast cancer patients and survivors. J Natl Compr Canc Netw 11: 1523–1530.

  32. , , , , , , , , , (2014) Actigraphy-measured sleep disruption as a predictor of survival among women with advanced breast cancer. Sleep 37: 837–842.

  33. , , , , , , , , (2011) Depression and incident stroke in women. Stroke 42: 2770–2775.

  34. , , , , , , , (2004) A prospective study of sleep duration and mortality risk in women. Sleep 27: 440–444.

  35. , , , , , , , , , , , (2016) Pre-diagnostic sleep duration and sleep quality in relation to subsequent cancer survival. J Clin Sleep Med 12: 495–503.

  36. , , , (2015) Sleep duration and breast cancer risk in the Breast Cancer Detection Demonstration Project follow-up cohort. Br J Cancer 112: 567–571.

  37. , , (1994) Test of the National Death Index and Equifax Nationwide Death Search. Am J Epidemiol 140: 1016–1019.

  38. , , , , (2011) Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. J Clin Oncol 29: 3580–3586.

  39. , (2001) Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 19: 895–908.

  40. , , , , , (2016) Insomnia and the risk of breast cancer: the HUNT study. Psychosom Med e-pub ahead of print 19 October 2016 doi:10.1097/PSY.0000000000000417.

  41. , (2003) Circadian disruption in cancer: a neuroendocrine-immune pathway from stress to disease? Brain Behav Immun 17: 321–328.

  42. , , (2016) Nighttime sleep duration, 24-hour sleep duration and risk of all-cause mortality among adults: a meta-analysis of prospective cohort studies. Sci Rep 6: 21480.

  43. , , , , , , (2012) Circadian disruption, sleep loss, and prostate cancer risk: a systematic review of epidemiologic studies. Cancer Epidemiol Biomarkers Prev 21: 1002–1011.

  44. , , , , , , , , , , , (2013) Sleep disruption among older men and risk of prostate cancer. Cancer Epidemiol Biomarkers Prev 22: 872–879.

  45. , , , (1993) Assessment of sleep in patients with lung cancer and breast cancer. J Clin Oncol 11: 997–1004.

  46. , (2007) Long sleep duration: a risk to health or a marker of risk? Sleep Med Rev 11: 337–339.

  47. , , , (2012) Sleep duration and endometrial cancer risk. Cancer Causes Control 23: 547–553.

  48. , , (2013) Which symptoms come first? Exploration of temporal relationships between cancer-related symptoms over an 18-month period. Ann Behav Med 45: 329–337.

  49. , , , , , , , , (2013) Association between sleep and breast cancer incidence among postmenopausal women in the Women's Health Initiative. Sleep 36: 1437–1444.

  50. , , , , , , , , , , , (2016) Statistical methods for studying disease subtype heterogeneity. Stat Med 35: 782–800.

  51. , (1992) The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 30: 473–483.

  52. , , , , , , , , (1987) Relative and absolute excess risks of coronary heart disease among women who smoke cigarettes. N Engl J Med 317: 1303–1309.

  53. World Health Organization (1967) International Statistical Classification of Diseases, Injuries, and Causes of Death, Eighth Revision. Geneva.

  54. , , , , , (2016) Sleep duration and breast cancer risk among black and white women. Sleep Med 20: 25–29.

  55. , (2006) Sleep and health: everywhere and in both directions. Arch Intern Med 166: 1686–1688.

  56. , , , , , , , , , , (2013) Sleep duration and cancer risk: a systematic review and meta-analysis of prospective studies. Asian Pac J Cancer Prev 14: 7509–7515.

  57. , (2014) Insomnia in adult survivors of childhood cancer: a report from project REACH. Support Care Cancer 22: 3061–3069.

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Acknowledgements

We would like to thank the participants and the staff of the Nurses' Health Study for their valuable contributions as well as the following American state cancer registries for their help: AL, AZ, AR, CA, CO, CT, DE, FL, GA, ID, IL, IN, IA, KY, LA, ME, MD, MA, MI, NE, NH, NJ, NY, NC, ND, OH, OK, OR, PA, RI, SC, TN, TX, VA, WA, WY. The Nurses’ Health Study is supported by grants UM1 CA186107 and P01 CA87969 by the National Institute of Health. CTF received a postdoctoral fellowship from the Canadian Institutes of Health Research.

Author information

Affiliations

  1. Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA

    • Claudia Trudel-Fitzgerald
  2. Department of Medicine, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA

    • Eric S Zhou
    •  & Wendy Y Chen
  3. Department of Medical Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA 02215, USA

    • Eric S Zhou
    •  & Wendy Y Chen
  4. Department of Medicine, Channing Division of Network Medicine, Brigham and Women’s Hospital, 181 Longwood Avenue, Boston, MA 02115, USA

    • Elizabeth M Poole
    • , Xuehong Zhang
    • , A Heather Eliassen
    • , Wendy Y Chen
    • , Michelle D Holmes
    • , Shelley S Tworoger
    •  & Eva S Schernhammer
  5. Department of Epidemiology, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA 02115, USA

    • Xuehong Zhang
    • , A Heather Eliassen
    • , Michelle D Holmes
    • , Shelley S Tworoger
    •  & Eva S Schernhammer
  6. Department of Epidemiology, UCLA Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA 90095, USA

    • Karin B Michels
  7. Department of Epidemiology, Medical University of Vienna, Marianneng. 14/Top 105, Vienna 1090, Austria

    • Eva S Schernhammer

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Competing interests

The authors assume full responsibility for analyses and interpretation of these data.

Corresponding author

Correspondence to Claudia Trudel-Fitzgerald.

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