Skip to main content
NCBI home page
Integrative Medicine Research logoLink to Integrative Medicine Research
. 2025 Aug 7;14(4):101213. doi: 10.1016/j.imr.2025.101213

Acupuncture versus cognitive behavioral therapy for anxiety among cancer survivors with insomnia: An exploratory analysis of a randomized clinical trial

Eunbin Kwag a, Xiaotong Li a, Sheila Garland b, Karolina Bryl a, Lauren Taylor a, Qing S Li a, Lindsay Amann a, Jun J Mao a, Kelly M McConnell c,⁎
PMCID: PMC12395375  PMID: 40896348

Abstract

Background

Anxiety and insomnia frequently co-occur among cancer survivors and are strongly interconnected, yet no widely accepted intervention simultaneously targets both symptoms.

Methods

Data were drawn from a dual-center, parallel-group, randomized, comparative effectiveness trial evaluating acupuncture versus CBT-I for insomnia. Seventy-six participants with baseline Hospital Anxiety and Depression Scale-Anxiety (HADS-A) scores of ≥8 were included. Both interventions were administered over eight weeks, with follow-up until 20 weeks. Anxiety was assessed at baseline, week 8, and week 20 using HADS-A. A linear mixed-effects model was used to examine mean change in HADS-A scores. Additionally, responder analyses were conducted, with insomnia and anxiety responders defined as patients demonstrating clinically meaningful improvements in either outcome by week 8.

Results

Both CBT-I and acupuncture significantly reduced HADS-A scores at week 8 (CBT-I: -3.75; acupuncture: -3.14) and week 20 (CBT-I: -3.05; acupuncture: -2.66) compared to baseline (all p < 0.001). There was no between-group difference (p=0.85). In responder analyses, CBT-I showed greater anxiety reduction in insomnia responders (-4.62) than non-responders (-0.45), at both time points (week 8: p=0.0046; week 20: p=0.038). In the acupuncture group, the difference in anxiety reduction between insomnia responders (-3.96) and non-responders (-1.58) was not statistically significant.

Conclusion

Both acupuncture and CBT-I effectively manage comorbid anxiety and insomnia in cancer survivors. Acupuncture may address these symptoms independently, while CBT-I may improve them in an interconnected manner.

Trial registration

ClinicalTrials.gov registration (NCT02356575).

Keywords: Acupuncture, Anxiety, CBT-I, Cancer survivors, Insomnia

1. Introduction

Anxiety and insomnia are common and troubling symptoms for cancer patients and survivors. Anxiety affects 17.9% to 43% of this population1,2 while insomnia impacts 30.9% to 54.3%, depending on the cancer type.3,4 Evidence shows that these two comorbidities not only frequently co-occur but are also strongly linked to each other.5,6 For example, two cross-sectional surveys with breast cancer patients found that insomnia was positively correlated with anxiety.7, 8, 9 Additionally, elevated anxiety was shown to predict insomnia in ovarian cancer survivors.10 This connection between anxiety and insomnia spans all phases of the cancer journey, including pre-operatively,7 during treatment,11 and through survivorship.12,13 Given the strong connection between insomnia and anxiety, addressing one symptom could potentially alleviate the other, thereby reducing the need for multiple treatments.14, 15, 16 However, there is currently no widely accepted intervention specifically designed to treat both insomnia and anxiety in cancer survivors.

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for insomnia in both general and cancer populations.10, 11, 12,17 CBT-I helps patients learn how to restore natural sleep patterns by teaching techniques to reduce the arousal associated with insomnia and encouraging lifestyle adjustments that align with the body’s circadian rhythm.18,19 Given the strong association between insomnia and anxiety, many CBT-I trials have also explored its potential to alleviate anxiety through insomnia treatment. While some evidence suggests that CBT-I may help reduce anxiety alongside improving sleep, other studies report mixed results.20, 21, 22

Acupuncture, originating from Traditional Chinese medicine, has shown promising effects in treating insomnia in both general and cancer patient population.10,14,15 Emerging evidence also supports acupuncture for the treatment of anxiety in cancer patients.23 A proposed mechanism of acupuncture for the alleviation of insomnia is the modulation of the activities of sympathetic and parasympathetic nervous systems.21,23, 24, 25 Recent guidelines from the Society for Integrative Oncology (SIO) and the American Society of Clinical Oncology (ASCO) recommend acupuncture for post-treatment anxiety, particularly in breast cancer patients.26,27 However, this recommendation is based on intermediate-quality evidence with a weak strength of recommendation, underscoring the need for further research to solidify the therapeutic role of acupuncture in this context.

In our recent comparative effectiveness trial, both acupuncture and CBT-I were associated with significant improvements in insomnia symptoms across various cancer types.18 In order to advance our understanding of the efficacy of these interventions for co-morbid insomnia and anxiety, this secondary analysis aims to: (1) compare the effect of acupuncture and CBT-I on anxiety in cancer survivors with comorbid insomnia; (2) explore whether patients who experienced a meaningful reduction in insomnia (responders) after acupuncture or CBT-I also show improvement in anxiety; and (3) explore whether participants who experienced clinically meaningful reduction in anxiety (responders) after acupuncture or CBT-I show improvement in insomnia.

2. Methods

2.1. Study design

This study analyzed data from the published CHOICE trial, which evaluated the comparative effectiveness of acupuncture and CBT-I in treating insomnia among cancer survivors.28 The trial was conducted from March 2015 to July 2017, with interventions administered over an eight-week period. Outcomes were assessed at baseline, week 8, and week 20. The study was approved by the institutional review boards at Memorial Sloan Kettering Cancer Center and the University of Pennsylvania (ClinicalTrials.gov Identifier: NCT02356575).

2.2. Study participants and procedures

English-speaking adult patients diagnosed with cancer of all types and stages were eligible. Active treatment with surgery, chemotherapy, and/or radiotherapy must have been completed at least 1 month prior to study initiation. Eligible patients scored ≥8 on the Insomnia Severity Index (ISI) 29 and met the criteria for insomnia disorder as defined by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.30 Participants were eligible if on stable doses of psychotropic medications for ≥6 weeks. Use of hypnotics or sedatives was allowed and monitored but not discontinued. Exclusion criteria included: 1) the presence of an untreated sleep disorder (e.g., delayed or advanced sleep phase syndrome, obstructive sleep apnea, or restless leg syndrome); 2) prior treatment for insomnia with acupuncture or CBT-I; 3) an untreated psychiatric disorder (e.g., major depressive disorder, bipolar disorder, schizophrenia, generalized anxiety disorder, posttraumatic stress disorder, or dementia); and 4) employment in shift work that could impair the ability to maintain a regular sleep schedule. Trained research staff members conducted a diagnostic interview to confirm each patient's eligibility for the study, which was then confirmed by the principal investigator. All analyses in this study were restricted to participants with a baseline Hospital Anxiety and Depression Scale-Anxiety (HADS-A) anxiety score of 8 or higher.

Once eligibility was confirmed, patients provided informed consent. They were then sequentially randomized in a 1:1 ratio to one of two treatment conditions using permuted block randomization with a secure computer system, ensuring full allocation concealment. Primary investigators, co-investigators, outcome assessors, and statisticians were blinded to treatment assignments. The study protocol has been previously published.31

2.3. Interventions

2.3.1. CBT-I

CBT-I is a manualized, multicomponent treatment that includes sleep hygiene, sleep restriction, stimulus control, cognitive restructuring, and relaxation training.32,33 The CBT-I intervention was delivered by four licensed therapists and five psychology trainees. All interventionists received training in CBT-I prior to study initiation and ongoing supervision throughout the study.31 Participants received 1 treatment a week for 5 weeks, followed by 2 bi-weekly sessions, for a total of 7 sessions over 8 weeks. The first session was 60 minutes and the remaining sessions lasted 30 minutes.

2.3.2. Acupuncture

Acupuncture is a therapeutic approach rooted in traditional Chinese medicine, which involves placing thin, sterile, single-use metal needles into the skin.34 In the parent trial, we implemented a semifixed, manualized acupuncture protocol featuring standardized points aimed at treating insomnia (Bilateral: Shenmen [HT.7], Sanyinjiao [SP. 6]; Midline: Baihui [GV. 20], Shenting [GV. 24]; Unilateral: Shenmen [Auricu- lar], Sympathetic [Auricular]) along with additional points to address any comorbid symptoms such as anxiety or pain, as needed. Acupoint selection was guided by a Traditional Chinese Medicine (TCM) acupuncture textbook.35 Participants underwent a total of 10 acupuncture sessions over the course of 8 weeks, with treatments occurring twice a week for the initial 2 weeks, followed by weekly sessions for the remaining 6 weeks. The first acupuncture visit was 60 minutes, and subsequent sessions lasted 30 minutes each.

2.4. Outcomes

2.4.1. Hospital anxiety and depression scale (HADS)

The HADS-A, a subscale of the HADS, is a commonly used measure of anxiety and depressive symptoms in the past week.36, 37, 38 The 7-item Anxiety and Depression subscale are scored on a 4-point scale ranging between 0 and 3 and summed for each subscale. Score cutoffs are 0–7 (normal), 8–10 (borderline), and ≥ 11 (clinically abnormal).36 The HADS-A, a subscale includes anxiety symptoms such as tension, worry, fear, panic, difficulties in relaxing, and restlessness was used to assess the anxiety in this study.36 Responders were defined patients who achieved 1.4 or more reduction in anxiety at week 8 (end of the treatment).We used 1.4 points as the minimal clinically important difference for the HADS-A.39

2.4.2. Insomnia severity index (ISI)

ISI is a validated self-report measure of insomnia symptoms, consequences, and associated distress over the prior two weeks.40 The seven-item questionnaire has been used in numerous populations including cancer survivors.29 Items are scored on a five-point Likert scale, ranging from 0 to 4, with higher scores representing more severe insomnia symptoms. Items are then summed to generate total scores of 0 to 28. Clinically meaningful cutoff values are <8 (no insomnia), 8 to 4 (mild insomnia), 15-21 (moderate insomnia) and 22 to 28 (severe insomnia).40 A reduction of eight of more points on the ISI scale indicates clinically significant improvements.41 Therefore, participants with a reduction of eight of more points on the ISI scale from baseline to week 8 (end of treatment) were considered “insomnia responders”.

2.5. Statistical analyses

The analyses in the current study were guided by intent-to-treat principles. Descriptive statistics were used to summarize baseline participant characteristics. We assessed the mean ISI and HADS-A scores in both treatment groups from baseline to week 8 and 20 using a linear mixed effect model.42 Fixed effects included treatment, time, the interaction between treatment and time, and baseline outcome. Subject-specific random intercepts were used to account for the correlation between repeated outcome measures. To assess whether mean changes in ISI score differed between anxiety responders and non-responders within each treatment group and to assess whether mean changes in HADS-A score differed between anxiety responders and non-responders, we used Wilcoxon Rank Sum Test. The sample size was predetermined by the parent study.43 All statistical tests were 2-sided. Statistical significance was set at P < .05. All statistical analyses were conducted using Stata (version 18.0; StataCorp LLC, College Station, Texas) and SAS (version 9.4; SAS Institute Inc, Cary, North Carolina) statistical software.

3. Results

3.1. Participant enrollment and characteristics

As previously reported,43 we screened 604 cancer survivors between February 2015 and March 2017. A total of 160 were enrolled in the parent study and randomized to either CBT-I or acupuncture, with 80 patients in each group. Among these, total 76 patients (47.5 % from parent study participants) reported an anxiety score greater than 7 at baseline and were included in this secondary analysis. All 76 completed insomnia and anxiety assessments at baseline and went on to receive CBT-I (n=39) and acupuncture (n=37). A total of 73 participants (38 in CBT-I and 35 in acupuncture) completed week 8 assessments and 73 participants (38 in CBT-I and 35 in acupuncture completed week 20 assessments. All 76 participants were included in this analysis (Fig. 1).

Fig. 1.

Fig 1

Open in a new tab

Consort diagram.

Participants’ demographic and clinical characteristics are reported in Table 1. The mean age was 58.1 years (SD,12.0 years). The majority of participants were women (48, 63.2 %) and white (56, 73.6%). Nearly all (67, 88.2%) had at least a college-level education. Diverse cancer types were represented, the most common being breast (40.8%) and prostate (17.1%). The mean time since diagnosis was 6.3 years (SD, 6.0 years) (Table 1).

Table 1.

Baseline characteristics of cancer survivors with comorbid insomnia and anxiety (HADS-A ≥ 8) from the CHOICE trial.

Total (n=76)
 CBT-I (n=39)
 Acupuncture (n=37)
Characteristics No. % No. % No. %
Age, mean (SD), yrs 58.1 (12.0) 56.6 (12.9) 59.7(11.0)
Gender, n (%)
 Male 28 (36.8) 15 (38.5) 13 (35.1)
 Female 48 (63.2) 24 (61.5) 24 (64.9)
Race
 White 56 (73.6) 27 (69.2) 29 (78.4)
 Non-white 20 (26.3) 12 (30.8) 8 (21.6)
Ethnicity
 Hispanic 2 (2.6) 2 (5.1) 0 (0)
 Non-Hispanic 74 (97.4) 37 (94.9) 37 (100)
Education
 High school or less 9 (11.8) 1 (2.6) 8 (21.6)
 College or above 67 (88.2) 38 (97.4) 29 (78.4)
Cancer Type
 Breast 31 (40.8) 16 (41.0) 15 (40.5)
 Prostate 13 (17.1) 8 (20.5) 5 (13.5)
 Colon/Rectal 5 (6.6) 3 (7.7) 2 (5.4)
 Head/Neck 5 (6.6) 3 (7.7) 2 (5.4)
 Hematological 3 (3.9) 2 (5.1) 1 (2.7)
 GYN 4 (5.3) 2 (5.1) 2 (5.4)
 Other† 15 (19.7) 5 (12.8) 10 (27.0)
Years since cancer diagnosis, mean (SD) 6.3 (6.0) 5.8 (6.7) 6.8(5.2)
Baseline ISI total score, mean (SD) 19.2 (4.1) 19.4(3.7) 19.0 (4.5)
HADS-A total score, mean (SD) 11.2 (3.1) 11.2 (3.3) 11.3 (3.0)
Open in a new tab

CBT-I, cognitive behavioral therapy for insomnia; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; ISI, Insomnia Severity Index.

Other†: include other types, and more than one cancer type.

3.2. Effect of CBT-I and acupuncture on anxiety

CBT-I and acupuncture resulted in statistically significant and clinically meaningful reductions in total HADS-A scores at week 8 (end of intervention) compared to baseline (CBT-I: -3.75 points; 95% CI: -4.70 to -2.80, p < 0.001; acupuncture: -3.14 points; 95% CI: -4.12 to -2.16, p < 0.001). Treatment effects persisted at week 20 (CBT-I: -3.05 points; 95% CI: -3.99 to -2.11, p < 0.001; acupuncture: -2.66 points; 95% CI: -3.63 to -1.68, p < 0.001). There was no significant between-group difference in anxiety reduction at week 8 (mean difference: 0.61; 95% CI: –0.75 to 1.97; p = 0.38) or at week 20 (mean difference: 0.39; 95% CI: –0.97 to 1.75; p = 0.57). CBT-I demonstrated large effect size at week 8 (Cohens d, 0.98) and moderate effect size at week 20 (Cohens d, 0.70) Acupuncture demonstrated large effect size at week 8 (Cohens d, 0.98) and week 20 (Cohens d, 0.81) (Fig. 2).

Fig. 2.

Fig 2

Open in a new tab

Effect of CBT-I versus acupuncture on anxiety.

Abbreviations. CBT-I, cognitive behavioral therapy for insomnia; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; ISI, Insomnia Severity Index. CBT-I and acupuncture resulted in significant reductions in total HADS-A scores at week 8 (end of intervention) compared to baseline (CBT-I: -3.75 points; 95% CI: -4.70 to -2.80, p < 0.001; acupuncture: -3.14 points; 95% CI: -4.12 to -2.16, p < 0.001). There is no between group difference overtime (p=0.85). Treatment effects persisted at week 20 (CBT-I: -3.05 points; 95% CI: -3.99 to -2.11, p < 0.001; acupuncture: -2.66 points; 95% CI: -3.63 to -1.68, p < 0.001).

3.3. Association between anxiety reduction and insomnia improvement during treatment

In participants receiving CBT-I, anxiety reduction was greater in insomnia responders (-4.62; 95% CI: -5.15 to -4.09) than insomnia non-responders (-0.45; 95% CI: -2.34 to 1.44) at week 8 (p=0.0046; Fig. 3A) and week 20 (p=0.038). Similarly, insomnia reduction was greater in anxiety responders (-12.33; 95% CI: -13.33 to -11.33) than non-responders (-6.57; 95% CI: -8.95 to -4.32) at week 8 (p=0.0048; Fig. 3B) and week 20 (p=0.013).

Fig. 3.

Fig 3

Open in a new tab

Association between anxiety reduction and insomnia improvement in CBT-I and acupuncture.

Abbreviations. CBT-I, cognitive behavioral therapy for insomnia; HADS-A, Hospital Anxiety and Depression Scale–Anxiety; ISI, Insomnia Severity Index; WK, week. A. Significant difference in HADS-A score changes between Insomnia Severity Index (ISI) responders and non-responders in the CBT-I group at both week 8 and week 20; B. Significant difference in ISI score changes between HADS-A responders and non-responders in the CBT-I group at both week 8 and week 20; C. No significant difference in HADS-A score changes between ISI responders and non-responders in the acupuncture group at either week 8 or week 20; D. No significant difference in ISI score changes between HADS-A responders and non-responders in the acupuncture group at either week 8 or week 20.

In participants receiving acupuncture, anxiety reduction was numerically greater in insomnia responders (–3.96; 95% CI: –4.56 to –3.36) than in non-responders (–1.58; 95% CI: –2.67 to –0.49) at week 8, but this difference was not statistically significant at week 8 (p = 0.18; Fig. 3C), and the difference remained non-significant at week 20 (p = 0.44). Similarly, insomnia reduction was greater in anxiety responders (–10.25; 95% CI: –10.59 to –8.75) than in non-responders (–6.37; 95% CI: –7.69 to –5.05) at week 8 (p = 0.68) and week 20 (p = 0.64; Fig. 3D), but these differences were not statistically significant.

4. Discussion

This study is the first to compare CBT-I and acupuncture for anxiety in cancer survivors with insomnia. We found that both interventions resulted in similar, clinically meaningful, and durable reductions in anxiety among cancer survivors with insomnia. This finding suggests that CBT-I and acupuncture are effective treatment options for cancer patients with anxiety and comorbid insomnia.

Our study contributes to a growing body of research supporting acupuncture's beneficial effect on anxiety. In line with the 2023 SIO and the ASCO guidelines that recommend acupuncture for anxiety in adult cancer survivors, our findings showed clinically meaningful and statistically significant reductions in anxiety in the acupuncture group.27 Our findings are consistent with prior randomized clinical trials (RCT) of acupuncture showing acupuncture’s significant effect in anxiety reduction.23,26,44 However, our study expands on this literature by demonstrating the durability of acupuncture’s effect over time. Further, our study explored the relationship between anxiety reduction and comorbid insomnia improvement. In the acupuncture group, we found no significant differences in anxiety score changes between insomnia responders and non-responders at weeks 8 or 20, nor in insomnia score changes between anxiety responders and non-responders. These findings suggest that anxiety improvement in the acupuncture group may not be closely tied to the degree of insomnia improvement, indicating the potential for distinct therapeutic pathways.

Our study also contributes to understanding the impact of CBT-I on anxiety in cancer survivors with insomnia. Although CBT-I is well established for treating insomnia, its impact on comorbid psychological symptoms, such as anxiety has shown inconsistent results.45, 46, 47, 48, 49, 50 Our study suggests that CBT-I is effective for reducing anxiety that is comorbid with insomnia over a 20-week follow-up. In contrast to acupuncture, where anxiety and insomnia symptom improvements may occur independently, CBT-I appears to produce more interrelated effects. Specifically, patients who had clinically meaningful reductions in insomnia also reported anxiety improvements, and vice versa. CBT-I is designed to treat insomnia by addressing factors that cause sleep disturbances, such as stress and tension.51 These same factors also contribute to anxiety and may be the single shared mechanism that is reducing anxiety and insomnia in this study. Through this shared mechanism, improvements in insomnia may correspond with reductions in anxiety. These findings also suggest that when CBT-I is ineffective for either insomnia or anxiety, it may be unlikely to improve the other symptom.

Based on the findings of our study, both acupuncture and CBT-I should be considered viable treatments for cancer survivors experiencing comorbid anxiety and insomnia. Since both treatments effectively reduced anxiety and insomnia, patient preference and treatment availability can be considered in treatment planning. However, our responder analyses suggest that patients with high levels of anxiety may benefit from starting with acupuncture, if available, as it appears to be effective regardless of the patient’s insomnia treatment response.

Treatments that reduce multiple symptoms are valuable in cancer patient populations. Cancer patients often experience multiple health conditions and polypharmacy is a significant concern.52,53 Further, these patients have numerous appointments related to cancer treatment and monitoring. In this context, non-pharmacological therapies that address multiple symptoms, such as acupuncture and CBT-I, offer a distinct advantage by reducing symptoms while managing appointment burden.

Our study has several limitations. First, as a secondary analysis, the sample size was not powered to test reductions in anxiety, which limits our ability to draw definitive conclusions. Second, the trial was designed as a pragmatic comparison between two active interventions, without a usual care or waitlist control group. As a result, some observed changes may be due to the natural course of symptoms. Third, we did not account for other treatments, such as medications, yoga, or other complementary therapies, that participants may have been using to manage anxiety or insomnia during the study. These uncontrolled concomitant treatments may have influenced symptom outcomes, and their impact cannot be fully disentangled from the effects of the study interventions. Future studies should systematically record and analyze concurrent treatment use to improve the interpretability of results. Fourth, since the primary goal of the parent study was insomnia management rather than anxiety reduction, the interventions were primarily designed for insomnia, and the secondary analysis focused on patients with both conditions. Additionally, there were differences in session structure and total contact time between the CBT-I and acupuncture groups, which may have influenced outcomes and limit direct comparisons. CBT-I was delivered by both licensed psychologists and trainees, whereas acupuncture was provided by licensed acupuncturists. These differences may have influenced outcomes and limit direct comparisons. Finally, the study was conducted at a large, urban academic cancer center, where patients may have higher adherence rates, which could limit the generalizability of our findings to other settings or populations.

Nonetheless, this study has several notable strengths. It is the largest RCT to date evaluating the effects of acupuncture versus CBT-I on anxiety in cancer survivors with comorbid insomnia. Furthermore, our investigation explored the relationship between anxiety reduction and improvements in insomnia. The study had high adherence to the interventions, a long-term follow-up, and minimal missing data, which collectively enhance the reliability and robustness of our findings.28

In conclusion, this study highlights the potential of acupuncture and CBT-I as effective interventions for addressing comorbid anxiety and insomnia in cancer survivors, with each therapy potentially working through different pathways. These findings underscore the importance of a personalized treatment approach that considers patient preferences, symptom presentation, and treatment response. Future research should focus on confirming these findings and examining which treatment is most effective for patients in order to inform a personalized approach to care.

Author contributions

Conceptualization: G.K., J.J.M.; Methodology: G.K., J.J.M.; Validation: Q.L.; Formal analysis: Q.L., G.K.; Investigation: L.A., Q.L., J.J.M; Resources: J.J.M.; Data curation: Q.L.; Writing – Original Draft: G.K., L.A.; Writing – Review & Editing: X.L., K.B., K.M.; Visualization: G.K., Q.L.; Supervision: J.J.M., K.M.; Project administration: J.J.M.,L.A.; Funding acquisition: J.J.M. All authors have read and approved the final manuscript.

Conflict of interest

The authors declare the following financial relationships: JJM reports grants from Tibet CheeZheng Tibetan Medicine Co. Ltd. and from Zhongke Health International LLC outside the submitted work. Other authors declare no conflicts of interest.

Funding

This research was supported by Patient-Centered Outcomes Research Institute (PCORI) award (grant number CER-1403–14292). This research was also supported in part by a National Institutes of Health/National Cancer Institute (NCI) Cancer Center grant (number P30 CA008748).

Ethics statement

This research was conducted at the University of Pennsylvania’s Abramson Cancer Center in Philadelphia, PA, and at the Memorial Sloan Kettering Cancer Center in New York, NY (ClinicalTrials.gov Identifier: NCT02356575, https://clinicaltrials.gov/ct2/show/NCT02356575) and followed the ethics guidelines.

Data availability

The data that support the findings of this study are available on request from the corresponding author.

Acknowledgments

We sincerely thank the CHOICE Study Patient Advisory Board members, the study participants, the study therapists, and the research staff for their support of this study.

References

  • 1.Mitchell A.J., Ferguson D.W., Gill J., Paul J., Symonds P. Depression and anxiety in long-term cancer survivors compared with spouses and healthy controls: a systematic review and meta-analysis. Lancet Oncol. 2013;14(8):721–732. doi: 10.1016/S1470-2045(13)70244-4. [DOI] [PubMed] [Google Scholar]
  • 2.Brandenbarg D., Maass S., Geerse O.P., Stegmann M.E., Handberg C., Schroevers M.J., et al. A systematic review on the prevalence of symptoms of depression, anxiety and distress in long-term cancer survivors: implications for primary care. Eur J Cancer Care Engl. 2019;28(3) doi: 10.1111/ecc.13086. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.Berger A.M., Parker K.P., Young-McCaughan S., Mallory G.A., Barsevick A.M., Beck S.L., et al. Sleep wake disturbances in people with cancer and their caregivers: state of the science. Oncol Nurs Forum. 2005;32(6):E98–126. doi: 10.1188/05.ONF.E98-E126. [DOI] [PubMed] [Google Scholar]
  • 4.Al M.M., Al S.M., Alsayed A., Gleason A.M. Prevalence of sleep disturbance in patients with cancer: a systematic review and meta-analysis. Clin Nurs Res. 2022;31(6):1107–1123. doi: 10.1177/10547738221092146. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 5.Niedzwiedz C.L., Knifton L., Robb K.A., Katikireddi S.V., Smith D.J. Depression and anxiety among people living with and beyond cancer: a growing clinical and research priority. BMC Cancer. 2019;19(1):943. doi: 10.1186/s12885-019-6181-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Stark D.P., House A. Anxiety in cancer patients. Br J Cancer. 2000;83(10):1261–1267. doi: 10.1054/bjoc.2000.1405. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Sun G.W., Yang Y.L., Yang X.B., Wang Y.Y., Cui X.J., Liu Y., et al. Preoperative insomnia and its association with psychological factors, pain and anxiety in Chinese colorectal cancer patients. Support Care Cancer. 2020;28(6):2911–2919. doi: 10.1007/s00520-019-05151-y. [DOI] [PubMed] [Google Scholar]
  • 8.Aggeli P., Fasoi G., Zartaloudi A., Kontzoglou K., Kontos M., Konstantinidis T., et al. Posttreatment anxiety, depression, sleep disorders, and associated factors in women who survive breast cancer. Asia Pac J Oncol Nurs. 2021;8(2):147–155. doi: 10.4103/apjon.apjon_65_20. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 9.Desai K., Mao J.J., Su I., DeMichele A., Li Q., Xie S.X., et al. Prevalence and risk factors for insomnia among breast cancer patients on aromatase inhibitors. Supportive Care Cancer. 2013;21:43–51. doi: 10.1007/s00520-012-1490-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Price M.A., Zachariae R., Butow P.N., deFazio A., Chauhan D., Espie C.A., et al. Prevalence and predictors of insomnia in women with invasive ovarian cancer: anxiety a major factor. Eur J Cancer. 2009;45(18):3262–3270. doi: 10.1016/j.ejca.2009.05.030. [DOI] [PubMed] [Google Scholar]
  • 11.Calvo-Schimmel A., Paul S.M., Cooper B.A., Shin J., Harris C., Oppegaard K., et al. Oncology outpatients with worse anxiety and sleep disturbance profiles are at increased risk for a higher symptom burden and poorer quality of life. Cancer Nurs. 2023;46(6):417–431. doi: 10.1097/NCC.0000000000001139. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Palesh O., Tolby L.T., Hofmeister E.N., Fisher S., Solomon N.L., Sackeyfio S., et al. Symptoms and survivorship needs differences between "good sleepers" and "bad sleepers" in survivors of breast and gynecologic cancers. Sleep Med. 2022;100:49–55. doi: 10.1016/j.sleep.2022.07.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Galiano-Castillo N., Arroyo-Morales M., Ariza-Garcia A., Fernández-Lao C., Fernández-Fernández A.J., Cantarero-Villanueva I. Factors that explain the cancer-related insomnia. Breast J. 2017;23(4):387–394. doi: 10.1111/tbj.12759. [DOI] [PubMed] [Google Scholar]
  • 14.Harvey A.G. A cognitive model of insomnia. Behav Res Ther. 2002;40(8):869–893. doi: 10.1016/s0005-7967(01)00061-4. [DOI] [PubMed] [Google Scholar]
  • 15.Li Y.I., Starr L.R., Wray-Lake L. Insomnia mediates the longitudinal relationship between anxiety and depressive symptoms in a nationally representative sample of adolescents. Depress Anxiety. 2018;35(6):583–591. doi: 10.1002/da.22764. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 16.Jansson-Fröjmark M., Lindblom K. A bidirectional relationship between anxiety and depression, and insomnia? A prospective study in the general population. J Psychosom Res. 2008;64(4):443–449. doi: 10.1016/j.jpsychores.2007.10.016. [DOI] [PubMed] [Google Scholar]
  • 17.Johnson J.A., Rash J.A., Campbell T.S., Savard J., Gehrman P.R., Perlis M., et al. A systematic review and meta-analysis of randomized controlled trials of cognitive behavior therapy for insomnia (CBT-I) in cancer survivors. Sleep Med Rev. 2016;27:20–28. doi: 10.1016/j.smrv.2015.07.001. [DOI] [PubMed] [Google Scholar]
  • 18.Rossman J. Cognitive-behavioral therapy for insomnia: an effective and underutilized treatment for insomnia. Am J Lifestyle Med. 2019;13(6):544–547. doi: 10.1177/1559827619867677. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.Altena E., Ellis J., Camart N., Guichard K., Bastien C. Mechanisms of cognitive behavioural therapy for insomnia. J Sleep Res. 2023;32(6) doi: 10.1111/jsr.13860. [DOI] [PubMed] [Google Scholar]
  • 20.Shin J.W., Kim S., Shin Y.J., Park B., Park S. Comparison of acceptance and commitment therapy (ACT) and cognitive behavior therapy (CBT) for chronic insomnia: a pilot randomized controlled trial. Nat Sci Sleep. 2023;15:523–531. doi: 10.2147/NSS.S409981. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 21.Shaffer K.M., Smith J.G., Glazer J.V., Camacho F., Chow P.I., Mattos M., et al. Effects of an internet-delivered insomnia intervention for older adults: a secondary analysis on symptoms of depression and anxiety. J Behav Med. 2022;45(5):728–738. doi: 10.1007/s10865-022-00353-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 22.Baron K., Hooker S. Next steps for patients who fail to respond to cognitive behavioral therapy for insomnia (CBT-I): the perspective from behavioral sleep medicine psychologists. Curr Sleep Med Rep. 2017;3(4):254–260. [Google Scholar]
  • 23.Höxtermann M.D., Buner K., Haller H., Kohl W., Dobos G., Reinisch M., et al. Efficacy and safety of auricular acupuncture for the treatment of insomnia in breast cancer survivors: a randomized controlled trial. Cancers (Basel) 2021;13(16):4085. doi: 10.3390/cancers13164082. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Ballegaard S., Muteki T., Harada H., Ueda N., Tsuda H., Tayama F., et al. Modulatory effect of acupuncture on the cardiovascular system: a cross-over study. Acupunct Electrother Res. 1993;18(2):103–115. doi: 10.3727/036012993816357548. [DOI] [PubMed] [Google Scholar]
  • 25.Syuu Y., Matsubara H., Kiyooka T., Hosogi S., Mohri S., Araki J., et al. Cardiovascular beneficial effects of electroacupuncture at Neiguan (PC-6) acupoint in anesthetized open-chest dog. Jpn J Physiol. 2001;51(2):231–238. doi: 10.2170/jjphysiol.51.231. [DOI] [PubMed] [Google Scholar]
  • 26.Molassiotis A., Bardy J., Finnegan-John J., Mackereth P., Ryder D.W., Filshie J., et al. Acupuncture for cancer-related fatigue in patients with breast cancer: a pragmatic randomized controlled trial. J Clin Oncol. 2012;30(36):4470–4476. doi: 10.1200/JCO.2012.41.6222. [DOI] [PubMed] [Google Scholar]
  • 27.Carlson L.E., Ismaila N., Addington E.L., Asher G.N., Atreya C., Balneaves L.G., et al. Integrative oncology care of symptoms of anxiety and depression in adults with cancer: society for integrative oncology–ASCO guideline. J Clin Oncol. 2023;41(28):4562–4591. doi: 10.1200/JCO.23.00857. [DOI] [PubMed] [Google Scholar]
  • 28.Garland S.N., Xie S.X., DuHamel K., Bao T., Li Q., Barg F.K., et al. Acupuncture versus cognitive behavioral therapy for insomnia in cancer survivors: a randomized clinical trial. J Natl Cancer Inst. 2019;111(12):1323–1331. doi: 10.1093/jnci/djz050. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 29.Bastien C.H., Vallières A., Morin C.M. Validation of the insomnia severity index as an outcome measure for insomnia research. Sleep Med. 2001;2(4):297–307. doi: 10.1016/s1389-9457(00)00065-4. [DOI] [PubMed] [Google Scholar]
  • 30.Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (5th ed.). Reference Reviews 2014;28(3):36-37.
  • 31.Garland S.N., Gehrman P., Barg F.K., Xie S.X., Mao J.J. CHoosing options for insomnia in cancer effectively (CHOICE): design of a patient centered comparative effectiveness trial of acupuncture and cognitive behavior therapy for insomnia. Contemp Clin Trials. 2016;47:349–355. doi: 10.1016/j.cct.2016.02.010. [DOI] [PubMed] [Google Scholar]
  • 32.Trauer J.M., Qian M.Y., Doyle J.S., Rajaratnam S.M., Cunnington D. Cognitive behavioral therapy for chronic insomnia: a systematic review and meta-analysis. Ann Intern Med. 2015;163(3):191–204. doi: 10.7326/M14-2841. [DOI] [PubMed] [Google Scholar]
  • 33.Woodward S.C. Cognitive-behavioral therapy for insomnia in patients with cancer. Clin J Oncol Nurs. 2011;15(4):E42–E52. doi: 10.1188/11.CJON.E42-E52. [DOI] [PubMed] [Google Scholar]
  • 34.Mao J.J., Kapur R. Acupuncture in primary care. Prim Care. 2010;37(1):105–117. doi: 10.1016/j.pop.2009.09.010. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Cheng X., Deng L. Foreign Language Press; 1987. Chinese Acupuncture and Moxibustion. [Google Scholar]
  • 36.Snaith R.P. The hospital anxiety and depression scale. Health Qual Life Outcomes. 2003;1:29. doi: 10.1186/1477-7525-1-29. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 37.Carroll B.T., Kathol R.G., Noyes R., Wald T.G., Clamon G.H. Screening for depression and anxiety in cancer patients using the hospital anxiety and depression scale. Gen Hosp Psychiatry. 1993;15(2):69–74. doi: 10.1016/0163-8343(93)90099-a. Jr. [DOI] [PubMed] [Google Scholar]
  • 38.Bjelland I., Dahl A.A., Haug T.T., Neckelmann D. The validity of the hospital anxiety and depression scale. An updated literature review. J Psychosom Res. 2002;52(2):69–77. doi: 10.1016/s0022-3999(01)00296-3. [DOI] [PubMed] [Google Scholar]
  • 39.Puhan M.A., Frey M., Büchi S., Schünemann H.J. The minimal important difference of the hospital anxiety and depression scale in patients with chronic obstructive pulmonary disease. Health Qual Life Outcomes. 2008;6:46. doi: 10.1186/1477-7525-6-46. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 40.Savard M.H., Savard J., Simard S., Ivers H. Empirical validation of the insomnia severity index in cancer patients. Psychooncology. 2005;14(6):429–441. doi: 10.1002/pon.860. [DOI] [PubMed] [Google Scholar]
  • 41.Morin C.M., Belleville G., Bélanger L., Ivers H. The insomnia severity index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011;34(5):601–608. doi: 10.1093/sleep/34.5.601. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Laird N.M., Ware J.H. Random-effects models for longitudinal data. Biometrics. 1982;38(4):963–974. [PubMed] [Google Scholar]
  • 43.Yang M., Liou K.T., Garland S.N., Bao T., Hung T.K.W., Li S.Q., et al. Acupuncture versus cognitive behavioral therapy for pain among cancer survivors with insomnia: an exploratory analysis of a randomized clinical trial. NPJ Breast Cancer. 2021;7(1):148. doi: 10.1038/s41523-021-00355-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.Mao J.J., Farrar J.T., Bruner D., Zee J., Bowman M., Seluzicki C., et al. Electroacupuncture for fatigue, sleep, and psychological distress in breast cancer patients with aromatase inhibitor-related arthralgia: a randomized trial. Cancer. 2014;120(23):3744–3751. doi: 10.1002/cncr.28917. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 45.Nissen E.R., Neumann H., Knutzen S.M., Henriksen E.N., Amidi A., Johansen C., et al. Interventions for insomnia in cancer patients and survivors-a comprehensive systematic review and meta-analysis. JNCI Cancer Spectr. 2024;8(3):pkae041. doi: 10.1093/jncics/pkae041. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 46.Savard J., Simard S., Ivers H., Morin C.M. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol. 2005;23(25):6083–6096. doi: 10.1200/JCO.2005.09.548. [DOI] [PubMed] [Google Scholar]
  • 47.Matthews E.E., Berger A.M., Schmiege S.J., Cook P.F., McCarthy M.S., Moore C.M., et al. Cognitive behavioral therapy for insomnia outcomes in women after primary breast cancer treatment: a randomized, controlled trial. Oncol Nurs Forum. 2014;41(3):241–253. doi: 10.1188/14.ONF.41-03AP. [DOI] [PubMed] [Google Scholar]
  • 48.Lau P., Starick E., Carney C.E. Anxiolytic impact of cognitive behavioural therapy for insomnia in patients with co-morbid insomnia and generalized anxiety disorder. Behav Cogn Psychother. 2024;52(4):456–460. doi: 10.1017/S1352465823000656. [DOI] [PubMed] [Google Scholar]
  • 49.Jansson-Fröjmark M., Jacobson K. Cognitive behavioural therapy for insomnia for patients with co-morbid generalized anxiety disorder: an open trial on clinical outcomes and putative mechanisms. Behav Cogn Psychother. 2021;49(5):540–555. doi: 10.1017/S1352465821000023. [DOI] [PubMed] [Google Scholar]
  • 50.Henry A.L., Miller C.B., Emsley R., Sheaves B., Freeman D., Luik A.I., et al. Does treating insomnia with digital cognitive behavioural therapy (Sleepio) mediate improvements in anxiety for those with insomnia and comorbid anxiety? An analysis using individual participant data from two large randomised controlled trials. J Affect Disord. 2023;339:58–63. doi: 10.1016/j.jad.2023.06.053. [DOI] [PubMed] [Google Scholar]
  • 51.Walker J., Muench A., Perlis M.L., Vargas I. Cognitive behavioral therapy for insomnia (CBT-I): a primer. Klin Spec Psihol. 2022;11(2):123–137. doi: 10.17759/cpse.2022110208. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 52.LeBlanc T.W., McNeil M.J., Kamal A.H., Currow D.C., Abernethy A.P. Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol. 2015;16(7):e333–e341. doi: 10.1016/S1470-2045(15)00080-7. [DOI] [PubMed] [Google Scholar]
  • 53.Ramsdale E., Mohamed M., Yu V., Otto E., Juba K., Awad H., et al. Polypharmacy, potentially inappropriate medications, and drug-drug interactions in vulnerable older adults with advanced cancer initiating cancer treatment. Oncologist. 2022;27(7):e580–ee88. doi: 10.1093/oncolo/oyac053. [DOI] [PMC free article] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data that support the findings of this study are available on request from the corresponding author.

Articles from Integrative Medicine Research are provided here courtesy of Korea Institute of Oriental Medicine

RESOURCES