Non-pharmacological sleep management in breast cancer survivors: Evidence from a systematic review and meta-analysis of RCTs

Abstract

Objective: Breast cancer is the most commonly diagnosed cancer among women worldwide. Although survival rates have improved through advances in screening and treatment, many survivors continue to experience chronic sleep disturbances that impair quality of life. This review synthesizes evidence from randomized clinical trials evaluating non-pharmacological interventions for sleep management in breast cancer survivors.

Methods: Following PRISMA guidelines, systematic searches were conducted in PubMed, EMBASE, Scopus, and Web of Science from inception to December 2024. Eighty-nine eligible studies were identified, and 73 met the predefined criteria for inclusion in the meta-analysis.

Results: Psychosocial interventions lead to substantial improvements in sleep quality (SMD = −1.12; 95% CI: −1.57, −0.68), while physical therapies, such as acupuncture, demonstrate moderate benefits (SMD = −0.86; 95% CI: −1.32, −0.41). Physical activity interventions showed minimal effects (SMD = −0.20; 95% CI: −0.39, 0.00). Additionally, psychosocial interventions significantly reduced insomnia symptoms (SMD = −0.82; 95% CI: −1.09, −0.55).

Conclusion: Nonpharmacological interventions, particularly psychosocial strategies, may effectively improve sleep quality and reduce insomnia among breast cancer survivors, supporting the integration of individualized supportive care plans within comprehensive survivorship and long-term follow-up programs.

Highlights

• •Breast cancer survivors often face ongoing sleep problems that lower their quality of life.
• •Evidence supports the effectiveness of non-drug interventions for improving sleep outcomes.
• •Psychosocial strategies help manage insomnia in breast cancer survivors.
• •Personalized survivorship care plans should include non-drug sleep interventions.

1. Introduction

Breast cancer, accounting for one in eight cancer diagnoses, is considered the most commonly diagnosed cancer and the leading cause of cancer-related deaths in women worldwide. The World Health Organization (WHO) estimates 2.3 million new cases of breast cancer each year, and this number is projected to increase by over 40% by 2040 in both developing and developed countries (Li et al., 2024; Tan et al., 2022).

Although breast cancer remains the most common cancer among women and its incidence is rising rapidly, the survival rate is improving thanks to advances in public awareness, early screening, and effective treatment. However, survivors often face multiple, persistent physical, emotional, and cognitive symptoms related to the diagnosis and aggressive treatments; these can include side effects such as fatigue, nausea and vomiting, sleep disturbances, changes in bowel function, altered taste, depression, and pain. These cancer-related symptoms frequently develop during treatment and can persist long after, significantly affecting quality of life (He et al., 2023; Li et al., 2024; Ullgren et al., 2018).

Impaired sleep is a distressing symptom experienced by breast cancer patients and survivors, not only at the time of diagnosis and treatment but also up to five years' post-treatment. Impaired sleep is considered a major risk factor for distress that can produce substantially negative health impacts, including increased morbidity, reduced quality of life, and impaired functional performance. Moreover, impaired sleep can interfere with cancer patients' overall adjustment to the disease, seeking medical treatment, and proper health-related behaviors (Kreutz et al., 2019; Samuel et al., 2021).

Sleep problems have sex-based differences, and insomnia is approximately 1.41 times more common in women than in men, which is associated with greater symptom distress and poorer outcomes (Wang et al., 2020). Recent evidence reveals that the global prevalence of sleep disturbances is 62% among breast cancer survivors. Pain, depressive symptoms, hot flashes, fatigue, non-Caucasian race, and menopausal status can increase the odds of developing sleep impairment in these patients (Leysen et al., 2019; Xin et al., 2024).

Similar to the general population with sleep impairment, breast cancer patients may use both pharmacological and non-pharmacological measures to manage sleep problems. In the acute stages, pharmacological approaches are typically among the most common options for managing sleep impairment in cancer survivors. However, they may inadvertently exacerbate other symptoms or produce new issues such as daytime sleepiness, drug dependence and tolerance, decreased cognitive function, and increased risk of adverse events. Non-pharmacological treatments may be preferable as they reduce the potential adverse outcomes associated with long-term pharmacological use (Jin et al., 2023; Li et al., 2024; Xin et al., 2024).

Previous evidence has demonstrated that non-pharmacological interventions such as standard exercise and rehabilitation programs, information provision, psychoeducation and symptom screening, cognitive-behavioral therapy, sleep hygiene education, and other approaches (including expressive therapy, expressive writing, healing touch, autogenic training, massage, muscle relaxation, mindfulness-based stress reduction, yoga, acupuncture, aromatherapy, music therapy, hypnotherapy, and guided imagery) are effective in reducing sleep impairment in cancer patients (Papadopoulos et al., 2018; Xin et al., 2024).

While non-pharmacological interventions are recommended as the preferred approach for alleviating cancer-related sleep problems, there are various types of these interventions, each with different advantages and disadvantages. However, there is still insufficient evidence and comprehensive research to determine which intervention is most effective (Papadopoulos et al., 2018).

There is an urgent need for systematic reviews and meta-analyses to provide clear information about the effects of non-pharmacological interventions on improving sleep quality in breast cancer patients. This evidence can inform the development of targeted interventions and personalized care plans. The results of this study aim to examine whether non-pharmacological interventions have a beneficial effect on managing sleep impairment among breast cancer patients.

2. Methods

This systematic review and meta-analysis were conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and adhered to a protocol registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD42024491702).

2.1. Search strategy and study selection

A systematic literature search was performed in PubMed, EMBASE, Scopus, and Web of Science from database inception through December 2024. The complete search terms and strategies applied in each database are presented in Table S1. In addition, the reference lists of relevant studies and review articles were manually examined to identify further eligible publications. Eligibility criteria were defined according to the PICOS framework, including population, intervention, comparison, outcomes, and study design. Eligible participants were women aged 18 years or older diagnosed with breast cancer. Interventions included any non-pharmacological approach targeting sleep impairment, such as dietary therapy, physical therapies, psychosocial interventions, physical activity, self-care, light therapy, mixed approaches, or related strategies. Control groups consisted of usual care, waiting-list controls, sham interventions, or placebo conditions. Outcomes of interest included sleep quality, insomnia, and sleep-related disorders. Only randomized controlled trials (RCTs) published in English were included. Two independent reviewers (S-Z.A. and M.M.) screened titles and abstracts, followed by full-text assessment of potentially relevant studies. Any disagreements were resolved through discussion or consultation with a third reviewer (Z.M-P.).

2.2. Quality assessment and data extraction

Methodological quality was assessed using the Cochrane Risk of Bias 2.0 tool. Data were independently extracted by two reviewers (Z.M-P. and S-Z. A.) using a standardized data collection form. Extracted data included study characteristics, population details, number of participants and cases, intervention and control conditions, outcome measures, and statistical estimates.

2.3. Statistical analysis

For each study, we extracted the baseline and post-intervention means and standard deviations (SDs) of the outcome scores (sleep quality, insomnia, and sleep disturbance) for the comparison groups. We then calculated the mean changes and their corresponding SDs. To summarize these changes across studies, standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Heterogeneity among studies was evaluated using the Q test and I² statistic. A visual inspection of funnel plots, Egger's regression asymmetry test, and Begg's adjusted rank correlation test were performed to assess publication bias. When the number of studies was fewer than 10, we did not assess the publication bias. Sensitivity analyses were conducted using a leave-one-out approach. All meta-analyses were conducted using Stata version 17 (StataCorp LP, College Station, TX, USA).

3. Results

3.1. Literature search and study characteristics

A total of 772 records were identified through database searching. After removing 220 duplicate records, 552 unique articles remained for screening. During title and abstract screening, 453 studies were excluded for several reasons, including lack of a control group (n = 9), irrelevant population (n = 145), inappropriate intervention (n = 8), non-randomized design (n = 49), unrelated outcomes (n = 103), non-original articles (n = 64), secondary analyses of RCTs (n = 22), protocol, pilot, or feasibility studies (n = 52), and unavailable full texts (n = 1). Subsequently, 99 full-text articles were evaluated for eligibility, of which 10 were excluded because of insufficient data. Ultimately, 89 studies were included in the systematic review, and 73 studies met the criteria for inclusion in the meta-analysis. The study selection process is illustrated in the PRISMA flow diagram shown in Fig. 1.

Fig. 1.

PRISMA flow diagram illustrating the literature screening and study selection process for eligible studies investigating non-pharmacological sleep management interventions among breast cancer survivors published through December 2024.

The characteristics of the included studies are presented in Table S2. The studies were published between 2005 and 2024 and conducted in 21 countries. Most studies originated from the United States (n = 26; 29%) and China (n = 22; 25%), followed by Iran and Australia (each n = 5; 6%) and Germany (n = 4; 4%). Sample sizes ranged from 16 to 363 participants.

The included studies evaluated a broad spectrum of non-pharmacological interventions, including psychosocial interventions such as cognitive behavioral therapy (CBT), mindfulness-based stress reduction (MBSR), psychotherapy, hypnosis, stress management, spirituality-based interventions, Tibetan sound meditation, and mindful awareness practices. Physical therapies primarily included acupuncture and acupressure, while physical activity interventions involved yoga, tai chi, aerobic exercise, walking programs, qigong, Pilates, resistance training, and dance movement therapy. Other approaches included lifestyle modification, music therapy, compression therapy, and combined interventions integrating exercise, diet, or acupressure. Sleep-related outcomes were commonly assessed using validated instruments, including the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), and PROMIS measures. Outcome assessments were conducted immediately post-intervention and at follow-up periods ranging from 1 to 6 months. Most control groups received standard care, educational materials, or waitlist conditions. Risk-of-bias assessment using the Cochrane RoB 2.0 tool indicated generally high methodological quality, although several studies showed some concerns or high risk related mainly to blinding procedures and selective outcome reporting.

3.2. Post-intervention findings

The meta-analysis showed that non-pharmacological interventions significantly improved sleep outcomes among breast cancer survivors (Table 1). Among the evaluated approaches, psychosocial interventions demonstrated the greatest improvement in sleep quality immediately after treatment, with a large pooled effect size (SMD = −1.12, 95% CI: −1.57, −0.68). This effect was statistically significant (p < 0.00). Nevertheless, substantial heterogeneity was detected among the included studies (I² = 95.52%), suggesting notable differences in intervention protocols, participant characteristics, and methodological designs. Despite the high heterogeneity, no significant evidence of publication bias or small-study effects was observed.

Table 1.

Summary of sleep-related outcomes and their associations with non-pharmacological interventions reported worldwide through December 2024 (post-intervention phase).

Outcome	Interventions	Control group	No. of studies	No. of participants	SMD (95% CI)	${\mathbf{I}}^{\mathbf{2}}$(%)	P value	Publication bias	Leave-one-out
Sleep quality	Physical therapies	Usual care	7	571	−0.86 (−1.32, −0.41)	86.07	<0.00	Not detected	No small-study effect
		Sham	4	332	−0.55 (−1.04, −0.06)	77.33	<0.00	Not detected	Small-study effect
	Psychosocial interventions	Usual care	19	2242	−1.12 (−1.57, −0.68)	95.52	<0.00	No	No small-study effect
	Physical activities	Usual care	21	1985	−0.20 (−0.39, 0.00)	78.46	<0.00	No	No small-study effect
		Sham	1	101	−0.20 (−0.58, 0.19)	–	–	Not detected	–
	Self-care	Usual care	5	339	−0.57 (−1.33, 0.19)	90.70	<0.00	Not detected	Small-study effect
	Mixed or other interventions	Usual care	5	467	−0.87 (−2.08, 0.34)	97.16	<0.00	Not detected	Small-study effect
Insomnia	Psychosocial interventions	Usual care	12	1134	−0.82 (−1.09, −0.55)	79.39	<0.00	No	No small-study effect
	Physical activities	Usual care	3	208	−0.79 (−3.88, 2.31)	98.52	<0.00	Not detected	Small-study effect
	Mixed or other interventions	Usual care	4	711	−0.30 (−0.52, −0.08)	54.21	0.09	Not detected	No small-study effect
Sleep disturbance	Psychosocial interventions	Usual care	3	191	−0.54 (−1.55, 0.48)	90.94	<0.00	Not detected	Small-study effect
	Physical activities	Usual care	4	217	−0.09 (−0.35, 0.18)	0.00	0.46	Not detected	No small-study effect

Subgroup analyses showed that CBT produced a moderate-to-large beneficial effect on sleep quality (SMD = −0.67, 95% CI: −0.90, −0.45, I² = 45.12%), with moderate heterogeneity indicating relatively consistent findings and stable treatment effects across studies. Although non-CBT psychological interventions demonstrated a larger pooled effect size for sleep quality outcomes (SMD = −1.27, 95% CI: −1.90, −0.64), heterogeneity was extremely high (I² = 96.55%), suggesting substantial inconsistency among studies. Furthermore, the subgroup difference test was not statistically significant (p = 0.08), indicating that the apparent superiority of non-CBT interventions over CBT was not statistically supported. These findings suggest that, while some non-CBT approaches may show strong effects in individual studies, CBT outcomes appear more robust and generalizable across different clinical settings.

Regarding insomnia severity, CBT demonstrated the strongest therapeutic benefit among all examined interventions. The pooled effect size was large and clinically meaningful (SMD = −1.09, 95% CI: −1.34, −0.84), with low-to-moderate heterogeneity (I² = 34.57%), indicating good consistency across studies. In contrast, other interventions showed a smaller pooled effect size (SMD = −0.65, 95% CI: −0.99, −0.30) and substantially higher heterogeneity (I² = 79.99%). Importantly, the subgroup difference test was statistically significant (p = 0.04), supporting the superiority of CBT over alternative interventions in reducing insomnia symptoms.

Physical therapies, including modalities such as acupuncture and acupressure, were associated with a moderate improvement in sleep quality (SMD = −0.86; 95% CI: −1.32, −0.41; I² = 86.07%). While signs of publication bias were observed in this category, small-study effects were not evident. In contrast, physical activity interventions demonstrated a small and borderline significant effect (SMD = −0.20; 95% CI: −0.39, 0.00; I² = 78.46%).

Self-care strategies, such as lifestyle interventions, showed moderate but statistically uncertain effects on sleep outcomes (SMD = −0.57; 95% CI: −1.33, 0.19; I² = 90.70%). Mixed or other interventions yielded variable results, with high heterogeneity across studies (SMD = −0.87; 95% CI: −2.08, 0.34; I² = 97.16%). Regarding insomnia symptoms, psychosocial interventions again demonstrated a moderate-to-large beneficial effect (SMD = −0.82; 95% CI: −1.09, −0.55; I² = 79.39%; p < 0.00). Conversely, physical activity interventions exhibited highly inconsistent results with wide confidence intervals (SMD = −0.79; 95% CI: −3.88, 2.31; I² = 98.52%). Mixed interventions provided a small but significant improvement in insomnia symptoms (SMD = −0.30; 95% CI: −0.52, −0.08; I² = 54.21%). The evidence base for sleep disturbances was limited. Psychosocial interventions did not demonstrate a significant effect (SMD = −0.54; 95% CI: −1.55, 0.48; I² = 90.94%), and physical activity interventions showed minimal impact (SMD = −0.09; 95% CI: −0.35, 0.18; I² = 0.00%).

Overall, these findings highlight the potential of non-pharmacological strategies—particularly psychosocial approaches—to improve sleep-related outcomes in breast cancer survivors. Detailed forest plots summarizing these results are presented in Supplementary Figs. 1–12.

3.3. Follow-up findings

Follow-up analyses conducted at 1, 3, and 6 months' post-intervention revealed that the positive effects of psychosocial interventions on sleep quality were generally maintained; however, the magnitude of these effects declined over time (Table 2). At 1 month, the effect was small and not statistically significant (SMD = −0.41; 95% CI: −0.89, 0.07; I² = 80.04%). By 3 months, the benefit had increased slightly and was significant (SMD = −0.50; 95% CI: −0.91, −0.10; I² = 83.68%). At 6 months, the effect persisted but was smaller (SMD = −0.29; 95% CI: −0.49, −0.10; I² = 29.86%).

Table 2.

Summary of the included sleep management outcomes and their associations with non-pharmacological interventions reported globally through December 2024 at 1-, 3-, and 6-month post-intervention follow-ups.

Outcome	Interventions	Control group	No. of studies	No. of participants	SMD (95% CI)	${\mathbf{I}}^{\mathbf{2}}$(%)	P value	Publication bias	Leave-one-out
After 1 month of the intervention
Sleep quality	Psychosocial interventions	Usual care	5	315	−0.41 (−0.89, 0.07)	80.04	<0.00	Not detected	Small-study effect
	Physical activities	Usual care	5	343	0.13 (−0.13, 0.39)	39.02	0.16	Not detected	Small-study effect
After 3 months of the intervention
Sleep quality	Psychosocial interventions	Usual care	6	666	−0.50 (−0.91, −0.10)	83.68	<0.00	Not detected	Small-study effect
	Physical activities	Usual care	9	923	−0.15 (−0.28, −0.03)	10.40	0.35	Not detected	No small-study effect
Insomnia	Psychosocial interventions	Usual care	4	372	−0.39 (−1.13, 0.34)	92.88	<0.00	Not detected	Small-study effect
	Mixed or other interventions	Usual care	3	348	−0.16 (−0.62, 0.30)	82.45	<0.00	Not detected	Small-study effect
After 6 months of the intervention
Sleep quality	Psychosocial interventions	Usual care	3	494	−0.29 (−0.49, −0.10)	29.86	0.24	Not detected	No small-study effect
	Physical activities	Usual care	5	287	−0.11 (−0.60, 0.38)	81.23	<0.00	Not detected	No small-study effect
Insomnia	Psychosocial interventions	Usual care	4	372	−0.33 (−1.10, 0.44)	93.50	<0.00	Not detected	Small-study effect

In contrast, physical activity interventions demonstrated minimal lasting effects. No significant benefit was observed at 1 month (SMD = 0.13; 95% CI: −0.1, 0.39), while a small but significant effect emerged at 3 months (SMD = −0.15; 95% CI: −0.28, −0.03), which was not sustained at 6 months (SMD = −0.11; 95% CI: −0.60, 0.38).

Regarding insomnia, the long-term benefits of psychosocial interventions appeared limited. At 3 months, the effect was small and non-significant (SMD = −0.39; 95% CI: −1.13, 0.34; I² = 92.88%), and at 6 months, it decreased further (SMD = −0.33; 95% CI: −1.10, 0.44; I² = 93.50%), suggesting reduced durability in alleviating insomnia symptoms. Supplementary Figs. 12–17 present detailed forest plots of these findings.

3.4. Risk of bias

Fig. 2 illustrates the distribution of risk of bias across the five domains assessed using the Cochrane RoB 2.0 tool. Overall, a substantial proportion of the included studies were judged to have a high risk of bias. The highest concerns were observed in domains related to deviations from intended interventions and outcome measurement. In comparison, the domains addressing the randomization process, missing outcome data, and selection of reported results were generally evaluated as low risk or as having some concerns. These findings highlight the importance of interpreting the pooled estimates with caution because potential methodological biases may have influenced the results of the included studies.

Fig. 2.

Summary of the risk-of-bias assessment of the included studies using the RoB 2.0 tool, as reported globally through December 2024.

4. Discussion

In this systematic review and meta-analysis, we synthesized evidence on the effectiveness of non-pharmacological interventions for sleep management in breast cancer survivors. The overall findings suggest that non-pharmacological strategies such as psychosocial approaches, physical therapies, and physical activity interventions can improve sleep-related outcomes. Specifically, psychosocial interventions produced the most substantial improvements in sleep quality immediately following the intervention.

The findings of the present meta-analysis demonstrated that cognitive behavioral therapy (CBT)-based interventions were effective in improving sleep quality and reducing insomnia severity. Overall, the findings suggest that CBT not only provides substantial efficacy in improving sleep-related outcomes but also demonstrates greater consistency and reliability compared with many other psychological interventions. Accordingly, CBT—I, which is considered the clinical gold standard for insomnia treatment, may be regarded as one of the most evidence-based and effective approaches for managing insomnia and sleep disturbances.

However, interpretation of these findings should be undertaken with caution due to the methodological limitations of the included studies. Many studies were rated as having a high risk of bias, particularly in the domain of outcome measurement. This represents a common challenge in behavioral interventions such as CBT-I and yoga, where blinding of participants and strict control of intervention delivery are often not feasible. Consequently, these studies are susceptible to expectancy effects and social desirability bias, which may contribute to overestimation of self-reported improvements in sleep outcomes. As a result, randomized controlled trials in this field are frequently judged to have a high risk of bias, especially regarding outcome measurement and adherence to intended interventions.

Sleep management is regarded as a major concern and one of the top five long-term challenges faced by breast cancer survivors (BCS). Sleep issues occur both before and after cancer diagnosis and treatment. As the incidence of breast cancer continues to increase while mortality rates decline, more BCS patients are expected to experience sleep problems in the future. Various factors influence these women's sleep, including physical and psychological changes resulting from diagnosis and treatment, as well as age, physical activity levels, pain, hot flashes, night sweats, medication use, anxiety, and depression (Song et al., 2025).

Breast cancer can significantly impact patients' mental health in various ways. Upon initial diagnosis, patients often experience considerable stress, fears about mortality, and challenges in coping with symptoms from treatments such as chemotherapy, radiation, and surgery. Additionally, there are interpersonal effects, including changes in body image, sexual health, and work-life balance. Many patients face lingering changes after their breast cancer treatment that persist even after treatment concludes, potentially leading to depression and shifts in identity. Ongoing fears of cancer recurrence or progression can also contribute to heightened anxiety. The most prevalent mental health issues among breast cancer patients include adjustment disorders, depression, anxiety disorders, and symptom-related problems such as insomnia (Ashton and Oney, 2024).

Although evidence from systematic reviews and meta-analyses indicates that non-pharmacological interventions do not encounter the same challenges as pharmacological treatments—such as side effects like daytime sleepiness, drug dependence, tolerance, decreased cognitive function, and an increased risk of adverse events like falls—there are still several challenges and limitations to their implementation.

Certain non-pharmacological interventions, such as psychosocial approaches, which have the greatest effectiveness in addressing sleep problems in breast cancer patients, tend to be time-consuming and require qualified practitioners for effective implementation in professional settings. Their effectiveness often develops slowly, and the requirements for implementation are considerable, prompting some patients to prefer medication instead. Additionally, many patients do not focus on their psychosocial well-being, resulting in a low uptake of psychological interventions. This can make these interventions expensive and less feasible for home-based applications. Invasive therapies like acupuncture require professional oversight due to potential adverse events, including bleeding, pain, infection, and damage to organs or nerve tissues. Moreover, interventions such as physical exercise can be physically demanding and may exacerbate cancer-related fatigue if the intensity and duration are not properly managed, which can limit patient participation and adherence (Long et al., 2024; Xin et al., 2024).

With respect to physical activity interventions, the relatively small effect size should be interpreted with caution. Many of the included exercise trials did not primarily target sleep improvement; rather, sleep outcomes were assessed as secondary endpoints within broader rehabilitation or supportive care programs. This distinction is important because interventions not specifically designed to address insomnia may lack the behavioral and physiological specificity required to produce clinically meaningful improvements in sleep.

In addition, considerable variability in exercise dose—including differences in intensity, frequency, and duration—as well as adherence challenges, particularly among individuals experiencing cancer-related fatigue, may have contributed to the limited observed effects. These findings suggest that exercise-based interventions for sleep management may require more targeted design and appropriate dosing to achieve optimal therapeutic benefit.

This review primarily reflects subjective perceptions of sleep improvement, as assessed using self-reported instruments such as the Pittsburgh Sleep Quality Index and the Insomnia Severity Index, rather than objective indicators of physiological sleep restoration. A major limitation is the lack of objective sleep assessments, such as polysomnography or actigraphy, to validate these reported outcomes. Consequently, it remains unclear whether the observed improvements represent genuine physiological changes in sleep or alterations in participants' perceptions of sleep quality.

Additionally, anxiety commonly experienced among breast cancer patients may further influence sleep perception. Anxiety has been associated with sleep state misperception, a phenomenon in which individuals perceive their sleep as inadequate or disturbed despite objective evidence demonstrating relatively normal sleep duration and architecture (Liang et al., 2022).

Another important consideration is the biological context of insomnia among breast cancer survivors. A large proportion of patients receive endocrine therapies, such as tamoxifen or aromatase inhibitors, which may contribute to insomnia through estrogen suppression and the induction of vasomotor symptoms, including hot flashes and night sweats, affecting up to 80–90% of patients. These therapies may also disrupt circadian rhythms and contribute to fatigue, joint pain, and anxiety, further impairing sleep quality, particularly during the early phases of treatment (Van Dyk et al., 2021).

These treatment-related mechanisms differ substantially from those underlying primary insomnia. However, many included studies did not stratify participants according to endocrine therapy status or treatment-induced menopause, limiting the ability to determine which interventions may be most effective for specific patient subgroups. Future studies should incorporate these clinical variables to facilitate more personalized and clinically meaningful recommendations.

In addition, the temporal pattern of intervention effects warrants consideration. Although short-term improvements in sleep outcomes were commonly reported, follow-up findings suggested that intervention efficacy tended to diminish over time, particularly by six months post-intervention. This decline indicates that the benefits of non-pharmacological interventions may not be sustained without continued reinforcement or support. Accordingly, maintenance approaches—such as booster sessions or integration of interventions into long-term behavioral routines—may be necessary to preserve treatment benefits over time.

Our study has several limitations. First, although strict inclusion and exclusion criteria were applied to reduce heterogeneity, substantial differences remained across studies regarding sample characteristics, intervention types, and stages of breast cancer. These variations suggest that environmental, psychological, and comorbid factors may have influenced the observed outcomes.

Second, although many studies reported short-term improvements in sleep outcomes following intervention, few evaluated long-term effects, limiting conclusions regarding the sustainability and durability of treatment benefits. Third, considerable variability existed in intervention duration and in the instruments used to assess sleep outcomes across different non-pharmacological therapies. The absence of standardized assessment tools may introduce measurement bias and contribute to heterogeneity in estimating intervention effectiveness for cancer-related sleep disturbances. In addition, the review primarily relied on subjective sleep measures, with limited use of objective assessments such as polysomnography or actigraphy. Therefore, it remains uncertain whether reported improvements reflected true physiological changes in sleep or changes in sleep perception.

Finally, the inclusion of heterogeneous patient populations—including individuals undergoing active treatment as well as long-term survivors—introduced additional variability. The mechanisms underlying insomnia may differ across these stages, with treatment-related factors such as pain and corticosteroid use predominating during active therapy, while psychological factors, including fear of recurrence and conditioned arousal, may play a larger role during survivorship. The absence of stratification by treatment phase limits the generalizability and interpretability of the findings. Future research should prioritize well-designed randomized controlled trials with larger sample sizes, standardized outcome measures, objective sleep assessments, and longer follow-up periods to better evaluate the efficacy, safety, and durability of non-pharmacological interventions for sleep disturbances in breast cancer patients.

5. Conclusion

This systematic review and meta-analysis provide encouraging evidence supporting the effectiveness of various non-pharmacological interventions, particularly psychosocial approaches, physical therapies, and physical activity interventions, in improving sleep outcomes among breast cancer survivors. The findings highlight the potential of these interventions to address sleep disturbances, which are important contributors to survivors' overall quality of life.

Overall, the synthesized evidence suggests that non-pharmacological interventions can improve sleep-related outcomes in this population. However, interpretation of the pooled findings—especially for psychosocial interventions—should be approached with caution due to substantial heterogeneity across studies. Variations in intervention characteristics, outcome measures, patient populations, and methodological quality may have influenced the observed effects. Despite these limitations, the findings support the incorporation of evidence-based non-pharmacological strategies into survivorship care and underscore the need for further high-quality, standardized, and longitudinal research in this field.

CRediT authorship contribution statement

Seyedeh Zahra Aemmi: Writing – review & editing, Writing – original draft, Project administration, Methodology, Funding acquisition, Conceptualization. Zahra Mohammadi-Pirouz: Writing – review & editing, Writing – original draft, Visualization, Methodology, Investigation, Formal analysis, Data curation. Maryam Moradi: Writing – review & editing, Methodology, Conceptualization.

Ethical consideration

An ethics permit was not necessary for this study.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A. Supplementary data

Supplementary material

Data availability

The authors do not have permission to share data.