Journal of Sleep Disorders: Treatment and CareISSN: 2325-9639

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Research Article, J Sleep Disor Treat Care Vol: 3 Issue: 4

Evaluation of Sleep Quality in Patients with Breast Cancer

Daísy Vieira de Araújo*, Romanniny Hévillyn Silva Costa, Dayane Caroliny Pereira Justino, Fabricya da Guia Araújo Batista, Fábia Barbosa de Andrade and Iris do Céu Clara Costa
Federal University of Rio Grande do Norte/Faculty of Health Sciences of Trairi. Rua Trairi, s/n. Centro. Santa Cruz-RN, Brazil
Corresponding author :Daísy Vieira de Araújo
Assistant Professor of II Undergraduate Course of Nursing at Federal University of Rio Grande do Norte/Faculty of Health Sciences of Trairi. Rua Trairi, s/n. Centro. Santa Cruz-RN, Brazil 59200-000
Tel: (83) 9322-8795
E-mail: [email protected]
Received April 08, 2014 Accepted August 27, 2014 Published September 01, 2014
Citation: Araújo DV, Costa RHS, Justino DCP, Batista FGA, Andrade FB, et al., (2014) Evaluation of Sleep Quality in Patients with Breast Cancer. J Sleep Disor: Treat Care 3:4. doi:10.4172/2325-9639.1000142


Evaluation of Sleep Quality in Patients with Breast Cancer

This study aimed to characterize the socio-demographic and clinical profile of patients with breast cancer and to evaluate their quality of sleep. It is an exploratory-descriptive research with quantitative approach, developed in the Rio Grande do Norte League against Cancer, a reference center in the city of Natal-RN, in the period from January to March of 2011. The data collection instruments were: clinical and socio-demographic score sheet, The Pittsburgh Sleep Quality Index, and Intervenient Factors Affecting Sleep Quality. The study included 52 women with a clinical diagnosis of breast cancer. They were between 51-60 years old (30.8%); married or in consensual union (46.2%); with household income of 1-2 minimum wages (84.6%); 57.8% had incomplete primary education; 73% were Catholic and 67.3% from the interior of the state. Clinically it was observed that the patients had diagnostic time not under 6 months (46.1%) and the treatment chosen was surgery (78.8%) or chemotherapy (44.2%). In addition, 59.6% presented changes in sleep quality. The chemotherapy or radiotherapy proved to be an intervenerto an unpleasant sleep (63%) due to pain symptoms (33.3%). Health professionals should understand the importance of sleep in the promotion of the quality of life for patients with breast cancer and act so as to track possible changes and look for interventionist measures.



Sleep; Breast Neoplasm; Quality of Life


Sleeping is a physiological and behavioral process which is essential for the proper functioning of the organism, especially considering that the individual spends about 1/3 of their lives sleeping. It is made evident, thus, the relevance of sleep for the health of human beings [1]. Therefore, the sleep reported by the individual themselves and its impact on the daily lives of healthy or sick people has become one of the mainfocusof attention for researchers.
As to Redeker e Hedges, in Furlani [2], sleep alterations are frequent in patients suffering from acute or chronic diseases and those who are hospitalized.
Breast neoplasm poses real threat to the lives of countless women, impacting negatively on their quality of life. It is, therefore, among the diseases which affect the sleep quality.
According to the National Cancer Institute (INCA), breast cancer is the second most common type of neoplasia worldwide and the most common among women. Each year about 22% of new cancer cases in women are diagnosed as being breast cancer. In 2014, 57,120 new cases of the disease are expected in Brazil, with 13,225 female deaths from it [3]. Thus, breast cancer constitutes a major public health problem both nationally and globally.
As stated by INCA [4], sleep disorders occur in about 12% to 25% of the general population. However, it is estimated that 45% of people with cancer experience sleep disturbances and have higher risk of insomnia and disorders of the sleep-wake cycle (SWC).
In a study conducted in Canada in 2002 on aspects related to sleep with patients from an oncology unit, the most frequently encountered problems were excessive fatigue (44%), leg restlessness (41%), insomnia (31%) and excessive sleepiness (28%). Those who reported higher prevalence of problems were those who presented breast and lung cancer [5].
This study ishence justified by the small number of researches addressing the SWC of patients suffering from breast cancer in the hospital referral services, especially in Rio Grande do Norte, Brazil. Furthermore, it is believed that the findings of this study will subsidize the laying of new foundations to build a broader and more applicable knowledge on the subject.
The intent is to alert health professionals for a relatively new care practice, but which shares borders with several health areas (neurology, oncology, pulmonology, psychiatry, otolaryngology, cardiology, pediatrics, among others), and which aims to encourage the systematic approach to the assessment of sleep so as to enable assistance to the patient considering all their completeness and uniqueness. Thereby, greater comfort and well-being can be provided for these patients in an attempt to minimize the physical, psychological and social burdens which they commonly face.
Therefore, this study aims to characterize the socio-demographic and clinical profile of patients with breast cancer and to evaluate the sleep quality of these.


This is an exploratory-descriptive study with a quantitative approach. The research was developed in the Rio Grande do Norte League against Cancer, Natal / RN, Brazil, referral health institution in the care of cancer patients in the state. The interviews were conducted during the period comprising January to March of 2011, from Monday to Friday, in the morning shift. The sample consisted of 52 patients diagnosed as new cases of breast cancer who were already undertaking oncological treatment or about to start it. The inclusion criteria for patients were: being 18 years of age or older, being able to respond intellectually, physically and emotionally to the instruments for data collection and demonstrating interest in voluntarily participating in the study. However, patients who sought care to conduct semiannual or annual check, i.e., older cases of breast cancer, did not take part on the research. The project was submitted to the Rio Grande do Norte League against Cancer Committee for Research Ethics and approved with number 194/10. Only those subjects who expressed interest in participating in the study voluntarily were included in the study. All their rights and duties were exposed, followed by signature of the informed consent form.
All the participants completed three instruments, namely: Socio- Demographic and Clinical Form (SCF), Pittsburgh Sleep Quality Index (PSQI) and Intervening Factors in the Quality of Sleep (IFQS).
The SCF aimed to obtain information concerning the sociodemographic data, as well as some clinical aspects (time of diagnosis, affected site, and current treatment). To fill this form data contained in the patient’s medical records were also consulted. The PSQI, in turn, was used to evaluate the sleep quality. It was originally published by Buysse [6] and consists of 19 items, some of which have subdivisions of up to ten sub-items. This questionnaire is based on 7 assessment components: 1. Subjective sleep quality; 2. Latency; 3. Sleep duration; 4.Habitual sleep efficiency; 5. Sleep Disorders; 6.Use of sleeping medication; and 7. Daytime dysfunction. The scores of the 7 components are summed up to generate the overall score of the research instrument, which can vary from 0 to 21. 0-4 scores indicate good quality of sleep, 5-10 refer to poor sleep quality and above 10 disclose sleep disorder [2,6,7].
Finally, the IFQS, instrument adapted to Furlani’s [2], aimed to identify the possible factors related to poor sleep quality, such as: emotional factors, symptoms of the disease and chemotherapy or radiotherapy. The IFQS questions related to hospitalization were not answered, some questions were adjusted to obtain information about whether the emotional / psychological and symptomatological factors of the disease would have influence on sleep in the course of the disease.
The data were analyzed using the statistical program Statistical Package for the Social Sciences (SPSS), version 17.0, whose analysis was done by means of the absolute and relative frequency, mean, median, standard deviation, as well as the analysis of the internal consistency of the scale. The obtained data were interpreted in accordance with the pertinent literature.


Socio-demographic and clinical characteristics of the interviewed
The population consisted of 52 patients (100%), whose age ranged from 32 to 79 years (mean of 54 years); 32.7% were married (n=17); 94.2% (n=49) lived with another person, in general, their family; and 69.2% (n=36) shared their room with at least one (01) other person. The level of education that prevailed was incomplete primary education (57.8% / n=30); 73% (n=38) of patients claimed to be Catholic; the family income declared was between one and two minimum wages (84.6% / n=44) and 67.3% (n=35) were from the interior of the state. Regarding the breast most affected by cancer, the left breast achieved 51.9% (n=27) of reports, while the right accounted for 48.1% (n=25) of the interviewees. Concerning the duration of the disease, the majority (46.1% / n=24) had been diagnosed for, at most, six months. As for the types of treatment for breast malignneoplasias, 41 patients (78.8%) underwent or would still undergo surgery and 23 (44.2%) were going to receive chemotherapy. It was observed that the majority of patients (57.7%) were subjected to a kind of oncologic treatment and 36.5% to an association of therapeutic measures against breast cancer.
Assessing the quality of sleep
From the data obtained after the application of the Pittsburgh Sleep Quality Index, it was statistically observed that patients go to sleep at 20.30h., have a sleep latency of about 38 minutes, wake up at about 8.00h., and consider they sleep about 6 hours and 45 minutes per night. This is depicted in Table 1.
Table 1: Distribution of the mean, median, and standard deviation of the sleep time for patients, Natal / RN, Brazil, 2011.
Table 2 shows the frequency with which certain factors, such as: the need to go to the bathroom (67.3%) and waking up in the middle of the night or early morning (59.6%) interfere with patients’ sleep quality.
Table 2: Weekly frequency at which the patients presented difficulty to sleep at night due to several factors, Natal / RN, Brazil, 2011.
When inquired about their sleep quality, most patients (86.5% / n=45) classified it as being good. A large portion of the patients did not need medication to sleep (82.7%) or present difficulties to perform daily life activities (88.5%) due to daytime sleepiness, as seen on Table 3. The same frequency (21) and percentage (44.4%) were found among patients who claimed not to have any in disposition or lack of enthusiasm and those who affirmed to have a lot of discomfort or lack of enthusiasm when the disease was discovered.
Table 3: Weekly frequency at which the patients required to take medication to sleep pills or had trouble to stay awake when performing any daily life activity, Natal / RN, Brazil, 2011.
From the calculation of the score of the Pittsburgh Sleep Quality Index, it was laid bare that 59.6% (n=31) of the participants presented changes in sleep quality, being 44.2% poor quality of sleep (score 5-10) and 15.4% sleep disturbance (score> 10).
In the assessment of the internal consistency of the scale a Cronbach's alpha of 0,811was obtained from the 21 items. This can be considered a significant value for the present study.
Intervenient factors on the sleep quality of patients with breast cancer
According to the data collected by the completion of the research instrument about the Intervenient Factors on the Sleep Quality, it was observed that 51.9% (n=27) of patients claimed they had received chemotherapy or radiotherapy, while 48.1% (n=25) alleged they had not been subjected to these types of treatments.
Among those who received chemotherapy or radiotherapy sessions (n=27), when questioned about their sleep, at the time, 37% (n=10) stated that every time during the treatment they had a pleasant sleep, followed by 29, 7% (n=8) who mentioned this had happened only a few times. On the other hand, when asked about the amount of times they had slept less than they would like, 37% (n=10) said ithad never happened, whereas 29.7% (n=8) said they had been through this discomfort most of the time they had undergone such treatments.
It was made evident that patients, who had undergone chemotherapy or radiotherapy, in a large proportion (59.2%), reported not having sleep interruptions followed by difficulty returning to sleep.
Regarding, therefore, the organic disorders, the majority (65.4% / n=34) stated that these had never interfered their sleep, whereas 38.6% (n=18) reported having had problems to sleep.
It is worth emphasizing that 67.3% (n=35) did not report pain as being a problem to sleep while 32.7% (n=17) reported that they had trouble sleeping at least once a week due to this symptom. It is important to point out that amongst the patients who presentedalgesia as an interference factor to sleep, 33.3% (n=6), reported that this effect is accentuated during chemotherapy sessions.
It was found that psychological/emotional factors, for the most part (63.5%), were not constituted as a problem to sleep by the patients. However, 36.5% (n=19) of them mentioned that, at least once a week, these factors altered their quality of sleep.
It was observed that the adoption of comfort measures (noise-free environment, dim light, stretching, and hygienic habits) was prevalent for 58.7% of women, followed by the religious habits (praying) before sleeping (36, 9%).


With advancing age, the circadian sleep-wake rhythm and architecture are modified. Elderly people often present chronic diseases, whose symptoms or even therapy used reflect in sleep alterations. Moreover, psychosocial factors, such as retirement, financial difficulties, isolation, and institutionalization can lead to disturbances, since they can cause sleep fragmentation and cause the elderly to have daytime naps in an attempt to escape from monotony [8]. In the present study, most women were young adults, with an average age of 54 years.
The patients shared a room with at least 01 (one) more person, a fact which is probably related to most of them being married, to the economic level of the studied population (low family income), which influences the living conditions of individuals, or in order to give physical and of emotional support to the patient. It was noticed that the risk of developing insomnia increases in people who live alone [9].
As to Buysse [6], the care in oncology has greatly evolved. Findings of studies point to the need for oncological care covering aspects related to the quality of the patients' sleep, especially during hospitalization. The substantiated knowledge is essential so that the health professional can subsidize their care actions and guide the staff concerning the importance of providing pleasant sleeping nights to the patients including during hospitalization.
The relationship between sleep disturbances and the level of education has been less significant, since both people with low education and those with university degrees have presented insomnia [9].
Most patients came from the interior of the state of Rio Grande do Norte. It is understood that the dislocation of these women to the reference unit in the treatment of oncology can cause physical and mental wear and, consequently, alter the quality and quantity of their sleep, given that many of the cities are far from the state capital.
With respect to clinical features, there was no means to obtain information regarding the current cancer staging, considering that the records had no update on this component.
Concerning the duration of the disease, most of the patients had been diagnosed for, at most, 06 months. It is worthy of mention that some of the women notice some sort of change in their breast, but because of fear, or believing that there will be no problem, they do not seek health care early.
The sleep disorders experienced by cancer patients can occur at different periods of patient care: in diagnosis, during and after treatment, and in the terminal phase. The incidence of this disorder in these patients is significant because it is around 30-50%, compared to 15% in the general population. In addition, 23 to 44% of cancer patients have this symptom after two to five years of treatment [10].
The demand for the health promotion or screening services is still not a distinguishing feature of Brazilian society. Women head to health facilities, most of the time, when in the presence of any signs and/or symptoms of the disease, a fact whichinfluences satisfactorily in the prognosis of the disease and in the quality of life of the women when the disease is diagnosed early [11].
The oncological treatments have strong psychological and emotional impact on the patients, especially when combined, given that the therapy constitutes the next step to the disease diagnose, often creating an expectation on the patient as to the outcomes of the treatments. This may generate anxiety, depression, and sleep disorders.
Moreover, in some cases, feelings of anxiety, fear and insecurity become present due to issues related to women's sexuality, since they may be reflections of the completion of the mastectomy or side effects of the chemotherapy, such as alopecia [2,12,13].
A study [13] showed that patients with breast cancer presented a sleep latency of 35.1 +/- 30.5 minutes, a result similar to this study, which was of 38 minutes. However, what is observed is that sleep latency, in this research, was subjective in nature, considering that there was no use of an actigraph (device which measures the subject’s movement during sleep).
According to Davidson et al. [5], awakening many times during the night is the most common type of insomnia in patients with cancer, as well as staying awake for a long time at night and waking up too early in the morning. Probably, such fact is related to the need to go to the toilet during the night, as mentioned by 35 interviewees, which may therefore reflect on waking in the middle of the night or early morning. The pain complaints or emotional changes can also influence in the changes in the sleep pattern of these women.
In this research, when questioned about their quality of sleep, most patients considered it as being good.This fact was contrary to the overall score of the Pittsburgh Sleep Quality Index, which showed that 59.6% had poor sleep quality. This finding may be explained by the fact that the women had seldom any perception of their own sleep and also that other factors, such as sleep disruption during the night, are the main cause of problems in the quality and quantity of sleep.
However, despite the poor quality of sleep, the majority (82.7%) were not taking hypnotics/anxiolytics. They applied comfort measures, such as noise-free environment, dim light, stretching and hygiene habits, as well as religious habits (praying).
Daytime sleepiness was not considered as a problem for most women during the performance of daily routine activities. This is probably due to the fact that they consider their sleep quality as being good and, therefore, restorative, or because of the habit of taking a nap during the day.
Although there are few studies which address issues related to the sleep of patients suffering from cancer, it is recommended that the health team prioritizes the quality of the specific oncologic treatment, as well as the impact caused by the disease and its treatment on the patients’ quality of life, whose sleep quality is understood as a constituent [14].


Given the aforementioned, it is imperative that educational campaigns continue to be widespread in the social media, once breast cancer is still the most frequent among women and the fact that many of these have a low level of education often influences the early diagnosis of the disease and, consequently, its prognosis and the patient’s quality of life.
In this study there was no record of how long the patient had noticed any symptoms or if they had performed clinical breast examination, mammography, or if they had periodic appointments with their gynecologist, or regarding their lifestyle. For future studies, these suggestions are thereby left as a way of evaluating the adherence of women to the primary and secondary prevention actions.
It is now up to the healthcare professionals to awaken as to the importance of sleep in the promotion of the quality of life of patients. Those should take action in order to track possible changes in the sleep of patients, which, in most cases, is due to other factors, either related to the symptoms of the disease, to its treatment, or to emotional and mental changes within the patients. It is important for the professional to be able to identify other problems that go beyond the hospital environment, such as those present in the familiar environment of each woman. Therefore, the relevance of the holistic approach to the patient is highlighted, so as to ensure their physical and emotional balance.


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