Efficacy of a Stepped‐Care Approach to Cognitive‐Behavioural Therapy for Insomnia (Can‐Sleep) in Adolescents and Young Adults With Cancer

ABSTRACT

Objective

Poor sleep is a common issue among adolescents and young adults (AYA) with cancer. The present study describes the feasibility and impact of the Can‐Sleep stepped‐care intervention for AYA with cancer.

Methods

A total of 51 AYA with cancer were screened. AYA who reported sleep disturbance (defined as insomnia severity index score [ISI] > 7) received self‐managed cognitive behavioural therapy for insomnia (SMCBT‐I) in the first instance (Step 1) followed by individual cognitive behavioural therapy for insomnia (ICBT‐I) if symptoms continued (Step 2). AYA screened as high risk for intrinsic sleep abnormalities (e.g., obstructive sleep apnoea) were referred to a specialised service.

Results

Of the 51 AYA, 38 participants reported sleep disturbance. In total, 37 AYA commenced SMCBT‐I, four attending the specialised sleep service prior. Thirty‐one (84%) completed Step 1. Of these, 45% improved and required no further treatment, and 55% (17) were eligible for ICBT‐I (ISI > 7). Following intervention, the SMCBT‐I group showed a significant decline in insomnia symptoms (p < 0.001, d = 0.84). Among the 17 AYA continuing to report sleep disturbance, 11 (65%) were referred to ICBT‐I, with 8 (73%) accepting and completing Step 2. Those who received the ICBT‐I showed a significant reduction in insomnia symptoms (p = 0.007, d = 1.33).

Conclusions

This study provides preliminary efficacy and acceptability of a stepped‐care intervention for sleep disturbances in AYA with cancer. A stepped‐care intervention may offer an effective and resource‐efficient method for managing sleep disturbance in AYA with cancer.

1. Introduction

Cancer is the second leading cause of years of life lost in adolescents and young adults (AYA) aged 15–24 in Australia [1]. Advances in screening and treatments have improved 5‐year survival from 79% to 90% over the last 3 decades [1]. With improved survival comes a growing population of AYA in need of ongoing care [2]. Recent statistics suggest 60%–90% of AYA who survive cancer experience adverse late effects [3], with studies documenting psychosocial and physical sequelae at least up to 10 years after active treatment [4].

AYA are particularly vulnerable to sleep disturbance due to complex physiological, hormonal and psychosocial changes characteristic of the developmental period [5]. Cancer and its treatments place AYA at a higher risk for sleep problems. Anticancer treatments (e.g., chemotherapy), side‐effects (e.g., pain), psychological distress (e.g., anxiety), frequent hospitalizations and medications (e.g., glucocorticoids) all markedly disrupt sleep [6, 7]. Accordingly, several studies have indicated AYA with cancer have significantly poorer sleep relative to the general population and healthy siblings [8, 9]. Moreover, sleep problems comorbid with cancer are most prevalent in younger individuals [7].

Prevalence rates for sleep problems in AYA with cancer range from 16.7% to 85% [6, 10, 11, 12], with variability reflecting differences in population (e.g., assessment around the time of diagnosis or during the treatment phase), assessment methodology and symptom classification [13]. Insomnia symptoms, are most common during cancer treatment (55%–85%) [6, 8, 12], however may persist for several years post treatment [8]. Insomnia is the sleep disorder with highest prevalence in AYA survivors [14]. Approximately, one third of AYA survivors report symptoms of insomnia [11, 13], and in 9.6%–30.8% of AYA, these symptoms exceed accepted thresholds for normal or mild levels of insomnia symptoms and are clinically significant [9, 14]. Left untreated, insomnia can impair health‐related quality of life [10, 12]. Insomnia in AYA with cancer have been linked with emotional distress (e.g., depression, anxiety, post‐traumatic stress), physical morbidity (e.g., migraines, pain), and impaired overall functioning [15]. This is of particular significance as AYA with cancer seek to resume normal life amidst significant developmental and social transitions [16]. Sleep interventions administered within routine care may minimize symptom severity and impact.

Cognitive behaviour therapy for insomnia (CBT‐I) has been endorsed as the gold standard, first‐line treatment for insomnia in a wide range of clinical populations [17]. The efficacy of CBT‐I in AYA and cancer populations has been demonstrated through meta‐analyses [17, 18]. Despite its effectiveness, CBT‐I remains underutilized among cancer populations [19]. A study with 54 participants found 72% of AYA with cancer reporting clinical insomnia required support, yet only 5.6% received treatment [14]. Access to non‐pharmacological sleep interventions has several challenges. Firstly, data suggests insomnia in AYA is frequently underrecognized in cancer settings [20]. This may reflect a lack of systematic sleep assessment [21], limited access to resources regarding common psychosocial late effects [22], and perceived barriers to discussing sleep concerns with clinicians [21]. Secondly, the logistical requirements and cost associated with conventional sleep intervention delivery (i.e., geographic distance, availability of practitioners) may present barriers within an oncology setting [23]. Thus, a successful model for addressing insomniain AYA with cancer must focus on both screening and treatment practices that are scalable, accessible and cost‐effective.

To support the dissemination of CBT‐I, several abbreviated formats have been evaluated (e.g., web‐based, bibliotherapy). To date, two studies have shown preliminary efficacy for modified CBT‐I in AYA with cancer [24, 25]. In the first trial, AYA survivors with insomnia received three 60‐min professionally administered CBT‐I sessions with a focus on behavioural strategies (N = 10) [24] resulting in an average 7.1 point reduction in the insomnia severity index [ISI], with results sustained at two months postintervention. A subsequent study (N = 22) [25] enrolled AYA survivors with elevated insomnia symptoms (ISI > 10) in a 6‐week online self‐administered CBT‐I program showing a 5.6‐point reduction in ISI. However, findings from a meta‐analysis in the general population revealed self‐administered CBT‐I yielded smaller improvements compared to face‐to‐face CBT‐I [26], findings replicated in another study in patients with breast cancer (8.2 vs. 6.2‐point reduction in ISI for professionally‐vs. self‐administered CBT‐I) [27].

A stepped‐care model may reflect one strategy toward addressing time and resource constraints while enabling intensive intervention for those who need it. A stepped‐care framework begins with less intensive treatments and progresses to more intensive treatments only if required, which optimizes resource allocation and promotes timely service delivery [28]. We recently showed a stepped‐care model with self‐managed CBT‐I via a booklet (step 1) had a 5.2‐point ISI reduction and group CBT‐I (step 2) an 11.2 point ISI reduction in adults with cancer [29]. Notably, 61% of participants did not require further treatment following self‐managed CBT‐I [29]. Another stepped‐care trial in adult cancer survivors with poor sleep showed 45% of participants responded to single sleep education session (step 1, with more than 7 point ISI reduction) with the rest stepped up to group CBT‐I [30]. Finally, a randomized noninferiority trial in adults with cancer found that stepped‐care was not inferior to standard 6‐week CBT‐I [31], with both reducing insomnia symptoms (8.2 and 9.2 point reduction on ISI, respectively) [31].

Summarizing current evidence, Daniel and colleagues [32] called for future research to focus on the development and evaluation of clinical sleep interventions in young people with cancer. The current research aimed to assess the efficacy of a stepped‐care intervention for identifying and addressing insomnia in AYA with cancer.

2. Method

2.1. Design

A detailed protocol is published [33]. The study utilized a prospective, single‐arm design to evaluate the Can‐Sleep stepped‐care intervention for AYA with subthreshold and clinical insomnia. Can‐Sleep comprised two steps, self‐management CBT‐I (SMCBT‐I) and individual CBT‐I (ICBT‐I). Consistent with a stepped approach, the program commenced with a low‐intensity and scalable 5‐week intervention (SMCBT‐I, Step 1), and if symptoms persisted, participants progressed to a more tailored intervention (ICBT‐I, Step 2). Study measures were assessed at pre‐intervention (T0, enrolment), immediately after Step 1 (T1, rescreen), and at the conclusion of Step 2 (T2, completion). The protocol was registered (ACTRN12622000792729) and approved by the Peter MacCallum Cancer Centre Human Research Ethics Committee (21/93L).

2.2. Participants

Participants were recruited from the Peter MacCallum Cancer Centre (Melbourne, Australia), between October 2021 and May 2022. Inclusion criteria were: (a) confirmed cancer diagnosis; (b) aged 16–25; (c) English fluency; (d) able to provide informed consent (assessed via clinical judgement). Although in some international contexts AYAs are defined as aged 15–39 years, the current study was restricted to individuals aged 16–25 years as it reflects the age range served by the adolescent and young adult cancer service in which recruitment took place. No restrictions were placed on time since diagnosis, cancer stage, or presence/absence of anti‐cancer treatment at enrolment.

2.3. Measures

2.3.1. Insomnia Severity Index (ISI)

The ISI [34] is a self‐report measure with 7 items rated on a 5‐point Likert scale (0 = ‘None’, 4 = ‘Very Severe’). Total scores range from 0 to 28, with higher scores reflecting increased severity. A cut off of > 7 was used to identify sleep disturbance based on established criteria (0–7 = No clinically significant insomnia; 8–14 = Subthreshold insomnia; 15–21 = Clinical insomnia [moderate]; 22–28 = Clinical insomnia [severe]). The ISI has been validated in AYA with cancer [35]. A distributional‐based minimally important difference (MID) in insomnia symptoms has been suggested in an oncology sample as a 2.8‐point change [36], corresponding to a 0.5 standard deviation difference.

2.3.2. Epworth Sleepiness Scale (ESS)

The ESS [37] is an 8‐item self‐report measure assessing daytime sleepiness. Excessive daytime sleepiness was included because it represents a clinically meaningful and functionally impairing consequence of insomnia. Respondents are asked to report the probability of falling asleep across eight common situations (e.g., watching TV). Responses range from 0 (‘would never doze’) to 3 (‘high chance of dozing’). Total scores range from 0 to 24. Scores > 10 were interpreted as clinically significant excessive daytime sleepiness.

2.3.3. Stop‐Bang

The STOP‐BANG [38] is an 8‐item self‐report measure assessing risk factors for obstructive sleep apnoea (OSA). Items are dichotomous (‘yes’, ‘no’) and total scores range from 0 to 8, with higher scores indicating higher risk of OSA. Total scores > 4 was classified as high risk of moderate to severe OSA. Restless Leg Screening Tool (RLST). The RLST is a purpose‐built self‐report measure comprising five dichotomous items (‘yes’, ‘no’) which reflect the diagnostic criteria for restless leg syndrome (RLS) in DSM‐5. Participants who endorsed all five items as ‘yes’ were considered at high risk of RLS.

2.4. Procedure

Hospital outpatient clinic lists for the upcoming week were screened for eligibility by the research team. Potentially eligible participants were approached for interest and to discuss the purpose and protocol of the study. If interested and consenting, participants were screened using the ISI and ESS to determine eligibility. Participants who met the criteria (> 7 ISI and/or > 10 ESS) were subsequently asked to complete screening measures for OSA (STOP‐BANG) and RLS (RLST).

Participants who scored high on the STOP‐BANG (> 4) and/or the RLST (i.e., yes to all questions) were referred to the Department of Respiratory and Sleep Medicine at the Royal Melbourne Hospital, Melbourne, Australia, for reviewThose who scored below these thresholds (i.e., were assessed as having low to moderate risk of OSA and/or RLS), as well as those who had already attended the Department of Respiratory and Sleep Medicine, were offered the intervention.

2.5. Intervention

2.5.1. Step 1: Self‐Management CBT‐I Resource (SMCBT‐I)

The 5‐week intervention was offered in a therapist‐assisted CBT‐I booklet. Self‐management has been recommended as the first step in stepped‐care models [27]. Participants received a 63‐page colour printed booklet modelled on the Can‐Sleep booklet we previously developed and published [29]. Materials were adapted for young people based on AYA focus group feedback and consultation with the Youth Cancer Action Board. Intervention components included: (1) stimulus control, (2) sleep hygiene, (3) responding to sleep‐related worries, and (4) managing treatment side effects.

A trained member of the clinical team provided support at two timepoints: (1) intervention outset, participants received tailored instruction on effectively utilising the resource; and (2) mid‐intervention (approximately week three), participants were phoned to answer queries, support strategy implementation and encourage adherence.

Participants were rescreened approximately 5 weeks after the initial screening (Step 1, T1) via phone or face‐to‐face. Participants who endorsed symptoms below threshold (ISI < 8), or who reported subclinical insomnia severity (ISI > 7 but < 15) and were content with their sleep improvements, did not receive additional intervention. Participants who continued to endorse sleep complaints (ISI > 7) progressed to Step 2.

2.5.2. Step 2: Individual CBT‐I (ICBT‐I)

Participants were offered four 50‐min, structured CBT‐I sessions with a trained psychologist. Sessions were delivered flexibly, either in‐person or via telehealth, guided by participant preference. Session content was inclusive of SMCBT‐I strategies with a focus of personalizing implementation as well as identifying and addressing barriers. Recommendations were tailored according to presenting concerns and subjective sleep diary reports (e.g., sleep restriction, time‐in‐bed) that participants were encouraged to keep. Participants were rescreened using the ISI in the week following the completion of the ICBT‐I sessions (T2) approximately 5 weeks.

2.6. Statistical Analysis

Descriptive statistics were calculated as frequencies and percentages (for discrete variables) and means and standard deviations (for continuous variables). Change in insomnia symptoms from pretreatment to posttreatment was tested using paired t‐tests. Statistical significance was set at two‐tailed α = 0.05. Clinical significance was based on the predefined threshold for ISI of 2.8. Effect sizes are the paired equivalent of Cohen's d, calculated as d _Δ = (M _post − M _pre)/SD_change, interpreted using conventional thresholds: 0.20 (small), 0.50 (medium), ≥ 0.80 (large). Missing data were excluded (complete case analysis).

3. Results

3.1. Sample Characteristics

Table 1 shows the demographic and clinical characteristics of the sample. Fifty‐one AYA (Age: M = 21.37, SD = 2.64) with cancer consented to participate in screening (see Figure 1). The sample was primarily Male (N = 30, 59%) with a haematology (N = 22, 43%) cancer or sarcoma (N = 17, 33%) streams and 90% had received chemotherapy. Of the 51 participants who completed the initial screening, 38 (75%) reported sleep difficulties (ISI > 7 and/or ESS > 10) and were invited to complete additional screening (OSA/RLS).

TABLE 1.

Social‐demographic and clinical characteristics of the screened population at T0.

	Sleep difficulty N = 38			No sleep difficulty N = 13	Total N = 51
	Sleep disturbance N = 33	High risk OSA/RLS N = 5	Total N = 38
Age (range: 16–26y), M (SD)	21.03 (2.62)	22.6 (1.34)	21.24 (2.53)	21.77 (3)	21.37 (2.64)
Sex: Female, N (%)	13 (39)	1 (20)	14 (37)	7 (54)	21 (41)
Cancer tumour group, N (%)
Haematological malignancies	13 (39)	2 (40)	15 (39)	7 (54)	22 (43)
Sarcoma	13 (39)	0 (0)	13 (34)	4 (31)	17 (33)
Neuro‐oncological cancers	3 (9)	1 (20)	4 (11)	1 (8)	5 (10)
Genitourinary cancers	2 (6)	1 (20)	3 (8)	1 (8)	4 (8)
Breast cancers	1 (3)	0 (0)	1 (3)	0 (0)	1 (2)
Thoracic cancers	1 (3)	0 (0)	1 (3)	0 (0)	1 (2)
Unknown primary	0 (0)	1 (20)	1 (3)	0 (0)	1 (2)
Cancer treatments N (%)
Chemotherapy	30 (91)	5 (100)	35 (92)	11 (85)	46 (90)
Surgery	14 (42)	2 (40)	16 (42)	1 (8)	17 (33)
Radiotherapy	7 (21)	2 (40)	9 (24)	0 (0)	9 (18)
Immunotherapies	1 (3)	3 (60)	2 (5)	1 (8)	3 (6)
ISI, M (SD)	13.58 (4.12)	13.6 (3.05)	13.58 (3.96)	5.23 (1.83)	11.45 (5.09)
Range	8–23	3–23	8–23	3–7	3–23
ESS, M (SD)	7.67 (4)	6.6 (2.97)	7.53 (3.86)	5.77 (1.69)	7.08 (3.51)
Range	0–16	2–10	0–16	2–8	0–16

Abbreviations: ESS = Epworth sleepiness scale; ISI = Insomnia severity index; OSA = Obstructive sleep apnoea; RLS = Restless leg syndrome.

FIGURE 1.

Participant flow chart. STOP‐BANG, assessed obstructive sleep apnoea; ESS = Epworth sleepiness scale; ICBT‐I = Individual cognitive behavioural therapy; ISI = Insomnia severity index; RLST = Restless leg screening tool, assessed restless leg syndrome; SMCBT‐I = Cognitive behavioural therapy self‐managed.

3.2. Step 1: SMCBT‐I And/Or Department of Respiratory and Sleep Medicine

Of the 38 participants who completed secondary screening, 5 (13%) scored at risk of OSA or RLS and were offered referral to the Department of Respiratory and Sleep Medicine. All 5 (100%) participants accepted the referral and 4 (80%) attended the service and were subsequently offered the SMCBT‐I intervention arm.

In total, 37 participants were offered the SMCBT‐I intervention (1 declined intervention (SMCBT‐I) after attending RMH Sleep clinic). Thirty‐seven (100%) participants commenced SMCBT‐I. Of those who started SMCBT‐I, 29 (78%) participants completed the 3‐week follow‐up call, and 31 (84%) completed posttreatment rescreening (T1). Following SMCBT‐I, 10 (32%) participants had ISI < 8. Sixteen (52%) participants endorsed subclinical insomnia severity (ISI > 7 and ISI < 15), 4 (13%) of which reported feeling satisfied with sleep improvements, with no need for further intervention. Results showed a significant time effect on the ISI from baseline (T0; M = 13.29, SD = 4.02) to post‐SMCBT‐I (T1; M = 9.65, SD = 4.61), mean difference = −3.65, t(30) = 4.21, p < 0.001, d _Δ  = 0.84.

3.3. Step 2: ICBT‐I

Following Step 1, 11 participants continued to report insomnia symptoms and were offered the ICBT‐I intervention. Eight (73%) accepted and completed ICBT‐I. Common reasons for declining were other health priorities or insufficient time. At T2, seven of the eight (88%) completed the ISI of which, three (43%) no longer met the criteria for sleep disturbance (ISI < 8), while four (57%) reported subclinical insomnia severity (ISI > 7 and ISI < 15). The difference between pre‐ICBT‐I (T1; M = 13.43, SD = 3.51) and post‐ICBT‐I (T2; M = 8.29, SD = 4.19) was significant, mean difference = −5.14, t(6) = 3.96, p = 0.007, d _Δ  = 1.33.

4. Discussion

This study demonstrated the preliminary feasibility and efficacy of Can‐Sleep stepped‐care as an insomnia intervention among AYA with cancer. All AYA offered self‐management CBT‐I (SMCBT‐I; step 1) accepted the referral (N = 37), with most completing the program (84%). Results showed SMCBT‐I was associated with significant pre‐post improvements in insomnia symptoms, with approximately half of AYA requiring no further sleep treatment. Of those referred to individual CBT‐I (ICBT‐I; step 2), most accepted (73%) and subsequently completed the intervention. Post ICBT‐I, data revealed a significant reduction in insomnia symptoms. Overall, 91% of AYA who completed the stepped‐care pathway based on reported symptoms (i.e., Step 1; or Step 1 & 2) successfully recovered (ISI < 8) or were satisfied with sleep improvements.

Findings are in line with other trials conducted in both adult [17], and AYA oncology populations [24, 25] that have shown low‐intensity and standard CBT‐I reduce insomnia symptoms. We have previously reported the preliminary efficacy of the Can‐Sleep stepped‐care sleep intervention in adults with cancer [29]. We extend on these findings by potentially showing the therapeutic benefits of Can‐Sleep in AYA with cancer. At post treatment, results showed a 3.65‐, and 5.14‐point reduction in insomnia severity for SMCBT‐I and ICBT‐I, respectively. The observed treatment response exceeds a previously defined minimally important difference in an oncology population (MID = 2.8) [36], and the effect sizes for both were large. Together, the data suggests SMCBT‐I and ICBT‐I have the capability to produce clinically meaningful improvements in insomnia symptoms among AYA with cancer.

Although the sample size was small, the findings indicate a somewhat smaller treatment response in AYAs compared with adults. For example, in the previous trial investigating Can‐Sleep in adults with cancer [29], SMCBT‐I produced a larger 5.2‐point deduction on the ISI, relative to the 3.65‐point change we report in this trial. Similarly, two studies in cancer survivors using an online sleep intervention (Sleep Healthy using the internet [SHUTi]) comprising six 1‐h modules, showed a smaller treatment response in AYA (5.6 points on ISI) [25] compared to adults (8.9 points on ISI) [39]. Indeed, this may be related to differences in age demographics. As previously discussed, AYA face particular vulnerability to experiencing subthreshold or clinical insomniaamid a significant developmental and transitional period and, thus, may not be as responsive to sleep treatment [16]. Relatedly, AYA with cancer have shown lower adherence to interventions compared to adults with cancer in similar protocols [25]. Treatment differences between adult and AYA, therefore, in part, may be linked to the distinct challenges unique to this developmental period (e.g., hormonal alterations, later circadian preference) that may reduce how amenable current sleep interventions are to AYA and/or may interfere with treatment engagement.

Other possible demographic factors contributing to this apparent difference include tumour type and gender. This diagnostic trend is likewise evident in the present trial with 76% having haematological cancer or sarcoma. Contrastingly, the most common diagnosis in studies with adults was breast cancer (35%–64%) [29, 39]. Similarly, across studies, females comprised 81%–86% of adult participants [29, 39], and only 41%–46% of AYA participants [25]. To date, the overwhelming majority of sleep literature in cancer have established the efficacy of CBT‐I in women with breast cancer [17]. Studies investigating CBT‐I in males and within cancer diagnoses more common in AYA, has received far less attention. Accordingly, it was speculated on the potential role of these demographic variables; nevertheless, future research is necessary to confirm factors contributing to differences across studies. Several findings suggest that the Can‐Sleep stepped‐care model may have potential for integration within cancer care setting. First, the model may reduce reliance on clinicians time whileincreasing access to intervention. In this sample approximately 45% of individuals with cancer that received low‐intensity sleep intervention demonstrated a short‐term response to treatment and required no further treatment. While this finding should be interpreted cautiously given the descriptive nature of the study, it is broadly consistent with response rates reported in the wider stepped‐care sleep intervention literature (44%–58%) [29, 30, 31]. Thus, these findings provide preliminary support for the feasibility of low‐intensity sleep interventions as a potentially resource‐efficient practice of addressing sleep concerns in a sizeable proportion of individuals with cancer and insomnia symptoms. However, further research using controlled and adequately powered designs is required to determine effectiveness and generalisability.

4.1. Clinical Implications

Our findings suggest subthreshold and clinical levels of insomnia are significant in AYA affected by cancer. This study outlined that a low‐intensity sleep intervention shows promise in mitigating insomnia symptoms in AYA with cancer. Future trials should explore how to optimise treatment efficacy (e.g., optimal frequency, duration, modality) whilst limiting participant burden as well as exploring the long‐term impacts of such intervention on AYAs with cancer and clinicians. Overall, the findings add to a growing body of literature in support of integrated sleep treatment in standard oncology care, to ultimately inform public policy development, funding decisions and clinical practice guidelines.

4.2. Study Limitations

This study has several limitations that should be acknowledged. First, the sample size was small, which limits the statistical power of the findings and reduces the generalisability of the results to broader AYA oncology clinical populations. Second, the descriptive nature of the study and absence of a control group further limit the generalisability of the findings of findings and the ability to draw definitive conclusions regarding the effectiveness or scalability of the intervention. Without a comparator, it is difficult to determine whether observed changes were attributable to the intervention itself, or other conditions. Third, sleep outcomes were subjectively reported. Reliance self‐report introduces potential recall bias and may not accurately reflect actual sleep patterns or disturbances. Fourthly, this study is that it was not guided by a formal behavioural intervention development framework (e.g., the NIH Stage Model or ORBIT model). The absence of a structured framework may limit the extent to which these findings can directly inform the optimisation and systematic implementation of CBT‐I for the AYA cancer population. A further limitation is that the study did not differentiate between cancer stage (e.g., early vs. advanced) or account for the intersectionality of participant characteristics. These factors may influence patient needs, as well as engagement with and response to intervention, and should be considered in future research. Finally, participation was voluntary, and individuals who agreed to take part may have been more motivated with participants potentially providing responses they believed would be viewed favourably by the researchers.

5. Conclusions

Can‐Sleep is Australia's first program to systematically capture and treat subthreshold and clinical levels of insomnia in AYA with cancer.the findings position Can‐Sleep as a resource‐efficient, evidence‐based approach for addressing sleep disturbance during cancer. With the establishment of a sound research‐base and effective clinical implementation, the Can‐Sleep stepped‐care sleep intervention may play a significant role in reducing the impact of cancer‐related poor sleep in AYA.

Funding

This study was supported by Department of Health. State Government of Victoria. The funders had no role in the study design, data collection, analysis, interpretation, or presentation of results.

Data Availability Statement

Research data are not shared.