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Waking up to the merits of mindfulness
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Up to half of all patients with cancer suffer some degree of insomnia. It might be because of pain, depression, or anxiety, or it could be related to their treatment. Consequently, an estimated 25–50% of all prescriptions for cancer patients are for sleep-inducing drugs. The development of cognitive behavioural therapy for insomnia (CBT-I) changed the landscape for treating sleeping disorders. “The systematic review evidence is consistent in showing that 5 hours of CBT will deliver sustained improvements to about 80% of treated patients”, explains Kevin Morgan, director of Loughborough University’s Clinical Sleep Research Unit. “It is the most effective first-line treatment and it is superior and safer than hypnotics”. A partly blinded, non-inferiority trial has now confirmed the clinical efficacy of mindfulness-based stress reduction (MBSR), a therapeutic programme involving meditation and yoga.
The researchers randomly assigned 111 patients with cancer who had insomnia to undergo either CBT-I (n=47) or MBSR (n=64). The primary outcome was a reduction in sleeplessness, as measured by the seven-item insomnia severity index. Patients reported increases in their total sleep time (36 min for CBT-I; 45 min for MBSR), reductions in the amount of time it took to fall asleep (22 min for CBT-I; 14 min for MSBR), and being awake for shorter periods during the night (roughly 35 min for both). Most importantly, “both groups felt better about their sleeping patterns”, noted co-author Sheila Garland (Perelman School of Medicine, University of Pennsylvania, PA, USA). Overall, CBT-I performed better. MBSR proved inferior immediately after completion of the programme, but non-inferiority was reported at 3-month follow-up (p=0·02).
“Although MBSR may produce clinically significant improvements with time, the treatment effects of CBT-I are both durable and rapid”, wrote the authors. Whether all this will filter down to patient care is unclear. “CBT-I remains unavailable for most patients”, said Morgan. “The point at which patients make complaints of insomnia is usually primary care, and primary care is wired up to prescribe tablets.” Garland reckons that in the USA matters are improving. “Most people in major urban centres will have access to both CBT-I and MBSR”, she said. Online therapeutic courses are helping to expand access. The next step, she added, is to shape treatment into personalised forms: “Maybe we should be looking not at an either/or but at a combined approach.”
Ian Hooton/Science Photo Library
Waking up to the merits of mindfulness
Published Online January 17, 2014 http://dx.doi.org/10.1016/ S1470-2045(13)70338-3 For the study, see J Clin Oncol 2014; published online Jan 6. DOI:10.1200/JCO.2012.47.7265
Talha Khan Burki
Preoperative MRI fails to reduce breast cancer recurrence Use of MRI to stage breast cancer before surgery does not reduce the risk of local or distant recurrence, according to results from the largest study yet to investigate this controversial issue. MRI is more sensitive than conventional imaging for detecting clinically occult cancer foci. As a result, it is often part of the presurgical assessment of women with newly diagnosed breast cancer, under the assumption that it improves surgical treatment and local control. But growing evidence suggests that preoperative MRI fails to improve re-excision rates after surgical treatment, and increases the risk of mastectomy. An international group of researchers has now investigated the longterm effect of preoperative MRI on recurrence risk by analysing individual person data from four studies www.thelancet.com/oncology Vol 15 February 2014
comparing patients undergoing preoperative MRI with those receiving only conventional imaging. Their meta-analysis included data for 3180 affected breasts in 3169 women newly diagnosed with breast cancer. Results showed no difference in the proportion of women free from local recurrence at 8 years (97% of those undergoing preoperative MRI vs 95% in those not having MRI; p=0·87). Multivariable modelling showed no significant effect of MRI on local recurrence-free survival (hazard ratio [HR] for MRI vs no MRI 0·88, 95% CI 0·52–1·51; p=0·65) or distant recurrence-free survival (HR 1·18, 95% CI 0·79–2·27; p=0·48). “This is an important study because it addresses a potential benefit of MRI for which there has been limited data, namely whether selection of patients for breast conserving surgery with MRI reduces the rate of
local recurrence”, comments Monica Morrow (Memorial Sloan Kettering Cancer Center, New York, USA). “The results clearly show that it does not, and, since this is a patient level metaanalysis, the usual criticism of study level meta-analyses, that patients who did receive MRI are not the same as those that did not, does not apply as adjustments were made for clinical features.” In the absence of a randomised controlled trial, the study authors— led by Nehmat Houssami (University of Sydney, Australia)—suggest that their meta-analysis provides the best available evidence of the association between MRI and tumour recurrence and should be used to guide clinical practice. Morrow thinks evidencebased guidelines should now be developed for preoperative MRI.
Published Online January 17, 2014 http://dx.doi.org/10.1016/ S1470-2045(13)70337-1 For the meta-analysis of MRI and breast cancer recurrence see J Clin Oncol 2014; published online Jan 6. DOI:10.1200/ JCO.2013.52.7515 For more on MRI and re-excision rates after surgery see CA Cancer J Clin 2009; 59: 290–302 For the study of MRI and risk of mastectomy see Ann Surg 2013; 257: 249–55
Susan Mayor e57
Up to half of all patients with cancer suffer some degree of insomnia. It might be because of pain, depression, or anxiety, or it could be related to their treatment. Consequently, an estimated 25–50% of all prescriptions for cancer patients are for sleep-inducing drugs. The development of cognitive behavioural therapy for insomnia (CBT-I) changed the landscape for treating sleeping disorders. “The systematic review evidence is consistent in showing that 5 hours of CBT will deliver sustained improvements to about 80% of treated patients”, explains Kevin Morgan, director of Loughborough University’s Clinical Sleep Research Unit. “It is the most effective first-line treatment and it is superior and safer than hypnotics”. A partly blinded, non-inferiority trial has now confirmed the clinical efficacy of mindfulness-based stress reduction (MBSR), a therapeutic programme involving meditation and yoga.
The researchers randomly assigned 111 patients with cancer who had insomnia to undergo either CBT-I (n=47) or MBSR (n=64). The primary outcome was a reduction in sleeplessness, as measured by the seven-item insomnia severity index. Patients reported increases in their total sleep time (36 min for CBT-I; 45 min for MBSR), reductions in the amount of time it took to fall asleep (22 min for CBT-I; 14 min for MSBR), and being awake for shorter periods during the night (roughly 35 min for both). Most importantly, “both groups felt better about their sleeping patterns”, noted co-author Sheila Garland (Perelman School of Medicine, University of Pennsylvania, PA, USA). Overall, CBT-I performed better. MBSR proved inferior immediately after completion of the programme, but non-inferiority was reported at 3-month follow-up (p=0·02).
“Although MBSR may produce clinically significant improvements with time, the treatment effects of CBT-I are both durable and rapid”, wrote the authors. Whether all this will filter down to patient care is unclear. “CBT-I remains unavailable for most patients”, said Morgan. “The point at which patients make complaints of insomnia is usually primary care, and primary care is wired up to prescribe tablets.” Garland reckons that in the USA matters are improving. “Most people in major urban centres will have access to both CBT-I and MBSR”, she said. Online therapeutic courses are helping to expand access. The next step, she added, is to shape treatment into personalised forms: “Maybe we should be looking not at an either/or but at a combined approach.”
Ian Hooton/Science Photo Library
Waking up to the merits of mindfulness
Published Online January 17, 2014 http://dx.doi.org/10.1016/ S1470-2045(13)70338-3 For the study, see J Clin Oncol 2014; published online Jan 6. DOI:10.1200/JCO.2012.47.7265
Talha Khan Burki
Preoperative MRI fails to reduce breast cancer recurrence Use of MRI to stage breast cancer before surgery does not reduce the risk of local or distant recurrence, according to results from the largest study yet to investigate this controversial issue. MRI is more sensitive than conventional imaging for detecting clinically occult cancer foci. As a result, it is often part of the presurgical assessment of women with newly diagnosed breast cancer, under the assumption that it improves surgical treatment and local control. But growing evidence suggests that preoperative MRI fails to improve re-excision rates after surgical treatment, and increases the risk of mastectomy. An international group of researchers has now investigated the longterm effect of preoperative MRI on recurrence risk by analysing individual person data from four studies www.thelancet.com/oncology Vol 15 February 2014
comparing patients undergoing preoperative MRI with those receiving only conventional imaging. Their meta-analysis included data for 3180 affected breasts in 3169 women newly diagnosed with breast cancer. Results showed no difference in the proportion of women free from local recurrence at 8 years (97% of those undergoing preoperative MRI vs 95% in those not having MRI; p=0·87). Multivariable modelling showed no significant effect of MRI on local recurrence-free survival (hazard ratio [HR] for MRI vs no MRI 0·88, 95% CI 0·52–1·51; p=0·65) or distant recurrence-free survival (HR 1·18, 95% CI 0·79–2·27; p=0·48). “This is an important study because it addresses a potential benefit of MRI for which there has been limited data, namely whether selection of patients for breast conserving surgery with MRI reduces the rate of
local recurrence”, comments Monica Morrow (Memorial Sloan Kettering Cancer Center, New York, USA). “The results clearly show that it does not, and, since this is a patient level metaanalysis, the usual criticism of study level meta-analyses, that patients who did receive MRI are not the same as those that did not, does not apply as adjustments were made for clinical features.” In the absence of a randomised controlled trial, the study authors— led by Nehmat Houssami (University of Sydney, Australia)—suggest that their meta-analysis provides the best available evidence of the association between MRI and tumour recurrence and should be used to guide clinical practice. Morrow thinks evidencebased guidelines should now be developed for preoperative MRI.
Published Online January 17, 2014 http://dx.doi.org/10.1016/ S1470-2045(13)70337-1 For the meta-analysis of MRI and breast cancer recurrence see J Clin Oncol 2014; published online Jan 6. DOI:10.1200/ JCO.2013.52.7515 For more on MRI and re-excision rates after surgery see CA Cancer J Clin 2009; 59: 290–302 For the study of MRI and risk of mastectomy see Ann Surg 2013; 257: 249–55
Susan Mayor e57