Multi-Stakeholder Perspectives on Managing Insomnia in Cancer Survivors: Recommendations to Reduce Barriers and Translate Patient-Centered Research into Practice

Abstract

Purpose:

Insomnia is a debilitating symptom experienced by nearly 60% of cancer survivors. Building on our prior research showing the clinical benefit of cognitive behavioral therapy for insomnia (CBT-I) and acupuncture, we organized a workshop of patient advocates and clinician stakeholders to understand the barriers and develop recommendations for the dissemination and implementation of these interventions.

Methods:

Participants completed a pre-workshop survey assessing their experiences with insomnia and barriers to insomnia treatment and participated in a workshop facilitated by professionals and patient experts. Responses from the survey were tabulated and the discussions from the workshop were content-analyzed to extract relevant factors that influence dissemination and implementation.

Results:

Multidisciplinary and stakeholder workshop participants (N=51) identified barriers to integrating sleep health interventions in cancer care, and proposed solutions and future recommendations for dissemination and implementation of evidence-based interventions to improve sleep health in cancer survivors. Barriers were identified in four categories: patient (e.g. knowledge, time, cost), clinician (e.g. education, time, capacity), institutional (e.g. space, insurance reimbursement, referrals), and societal (e.g. lack of prioritization for sleep issues). Based on these categories, we made six recommendations for dissemination and implementation of research findings to improve clinical sleep management in oncology.

Conclusion:

Dissemination and implementation efforts are necessary to translate research into clinical practice to improve patient care.

Implications for Cancer Survivors:

Sleep needs to be prioritized in cancer care, but patient, provider, and institutional/societal barriers remain. Dedicated effort and resources at each of these levels are needed to help millions of people affected by cancer manage their insomnia and improve their quality of life.

INTRODUCTION

Nearly 60% of cancer survivors experience sleep disturbances in the form of insomnia,[1, 2] which can be unrelenting if not appropriately treated.[2] Insomnia is defined as a dissatisfaction with sleep quality and/or quantity characterized by difficulty falling asleep and/or staying asleep and can worsen physical and mental health symptoms in cancer survivors, including pain, fatigue, anxiety, and depression;[3] increase risk of infections;[4] and contribute to poor quality of life up to ten years post diagnosis.[5] Further, insomnia symptoms significantly contribute to healthcare expenditures and work absenteeism, highlighting that treatments to improve insomnia may have secondary economic benefits for patients and society.[6] Considering the prevalence, significance, and impact of insomnia, providing efficacious interventions has the potential to significantly improve patient quality of life and reduce the societal impact of cancer.

We recently completed the CHOICE study (Choosing Options for Insomnia in Cancer Effectively), which was the largest comparative effectiveness trial of two non-pharmacological treatments for insomnia in people diagnosed with cancer.[7, 8] CHOICE compared acupuncture and cognitive behavioral therapy for insomnia (CBT-I) in a heterogeneous sample of 160 people diagnosed with cancer. CBT-I, a form of CBT specifically designed to treat insomnia, is highly effective among people diagnosed with cancer.[9] CBT-I has demonstrated efficacy in many randomized controlled trials [10–12] and is recommend as a first line treatment for insomnia.[13–16] In comparison, acupuncture has been found to be efficacious for improving subjective insomnia symptoms and objective sleep efficiency compared with sham acupuncture in the general population.[17, 18] Further, acupuncture has increasing evidence for symptom management in people diagnosed with cancer for conditions such as pain and hot flashes that often can interrupt sleep.[19–22] Our comparative effectiveness study demonstrated that CBT-I was more effective than acupuncture overall; however, both treatments produced clinically meaningful reductions in insomnia severity and other symptoms.[8]

Despite the existence of well-established interventions to treat insomnia in cancer survivors and guidelines that recommend screening and treatment of insomnia in cancer settings [23, 24], dissemination and implementation of behavioral interventions for insomnia have been poor. [25, 26] Very little is known about the existing patient, provider, and institutional barriers to implementation of these interventions in oncology settings. A 2007 study by Davidson and colleagues explored perceptions of 26 cancer survivors on how to provide insomnia interventions. [27] Themes identified included the need for increased patient and provider awareness of the importance of sleep during and after cancer treatment and that the screening, diagnosis, and treatment of insomnia needs to be built into the cancer system with specific orders for treatment, follow up, and funding.

A number of studies have called on physicians and nurses to routinely ask their patients about their sleep [28–30]. In a survey of 25 adult survivorship programs at NCI-designated cancer centers, over half of centers screened fewer than 25% of people diagnosed with cancer for sleep-related issues. [31] When problems are identified, these professionals are often limited to medications as a treatment option as nonpharmacological options are largely unavailable. In the study above, only 13% of cancer centers referred their patients to CBT-I.[31] Similarly, while the availability of acupuncture is increasing in cancer centers;[32] only an estimated 10% of patients with cancer have used acupuncture,[26] and patients and clinicians often lack accurate and fundamental information surrounding the treatment.[33] These findings indicate that evidence-based screening tools and interventions are not being utilized by patients or providers, highlighting the need for optimal strategies to disseminate our research findings and implement these interventions.

Although definitions can vary[34], herein we apply the definitions of dissemination and implementation proposed by Glasgow and colleagues. [35] Dissemination is defined as “the targeted distribution of information and intervention materials to a specific public health or clinical practice audience with the intent to spread knowledge and the associated evidence-based interventions.” whereas implementation is “the use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings”. To formulate stakeholder recommendations for dissemination of the CHOICE study findings and guide implementation research on how to make these services available and accessible in routine cancer care, we conducted a half-day knowledge-to-action workshop, “Sleeping Well After Cancer: Translating Patient-Centered Research Into Practice,” as part of the Society for Integrative Oncology 16^th International Conference in New York, NY. The workshop drew on a scientific team of sleep and integrative oncology experts and patient stakeholders to identify barriers to optimal sleep management in cancer as well as recommendations to improve dissemination and implementation of CBT-I and acupuncture to manage insomnia in cancer survivors.

METHODS

Patient/advocate co-investigators were involved in formulating the workshop concept, designing workshop content, selecting patient advocate scholarship recipients, and serving as workshop facilitators. We contacted the 49 National Cancer Institute-designated Comprehensive Cancer Centers and 20 community cancer programs across the United States via email and asked them to identify and invite patient advocates and clinicians interested in improving sleep management at their cancer centers to participate in our workshop. Eligible patient advocates were at least one year out of primary cancer treatment and belonged to an advocacy organization or represented a constituency to disseminate information (e.g., the American Cancer Society). Eligible clinician stakeholders were associated with a cancer center or community oncology program and were motivated to increase awareness and treatment of insomnia for patients with cancer. As applications came in, our patient/advocate co-investigators and project lead evaluated them and came to consensus on who should attend with attention to the eligibility criteria and geographic and ethnic/racial diversity.

Fifty-one cancer survivor patient advocates and clinician stakeholders from National Cancer Institute (NCI)-designated Comprehensive Cancer Centers and community cancer centers with an interest in sleep in cancer care were invited to attend. Of the participants who attended the workshop, 76% (n=38) completed a pre-workshop survey assessing personal and/or professional experience with insomnia, awareness of CBT-I and acupuncture as treatments for insomnia, and frequency with which clinicians inquired about sleep issues after a cancer diagnosis. We also assessed their perception of barriers that: 1) affect cancer patients’ use of non-medication treatments like CBT-I and acupuncture to treat their insomnia, and 2) clinicians face in referring and/or providing their patients with such treatments. See Appendix A for the pre-workshop survey.

The workshop was conducted in three phases and the entire workshop was recorded and transcribed for later analysis. Patient advocates and clinician stakeholders were divided into small intermixed groups of eight to initially discuss barriers to and strategies for dissemination and implementation of insomnia treatments. The representative from each of the small groups then shared the findings with the entire group for a larger discussion. During Phase I (60 minutes), participants discussed the challenges attendees personally experienced or observed in their cancer care settings with respect to the diagnosis and management of insomnia. During Phase II (60 min), participants explored current strategies and approaches to reduce barriers and increase access. Lastly, in Phase III (60 min), based on the discussion during Phase I and II, groups developed an initial list of recommendations for increasing: 1) awareness of insomnia in patients and clinicians; 2) awareness of the evidence-base and availability of CBT-I as a therapeutic option in cancer clinical care settings; 3) awareness of the evidence-base and availability of acupuncture and other mind-body approaches as therapeutic options in cancer clinical settings; and 4) support of patients and providers to make informed decisions about better sleep during and beyond cancer treatment.

We used an integrated approach to the analysis of the data. [36] Two forms of codes were used: an a priori set of codes derived from the key ideas we were seeking to understand (e.g., patient, provider, and institutional/social barriers) and a set of codes that emerged from the data themselves (e.g., suggestions for dissemination and implementation). A data dictionary was developed that included all codes, their definitions, and decision rules for applying the code. The preliminary themes and recommendations were shared with the study team, which includes patient/advocate co-investigators, to ensure that perspectives were well captured. Any discrepancies were resolved by consensus within the study team.

RESULTS

Clinicians represented 53% of attendees while cancer survivors/patients/advocates comprised the remaining participants. Professions represented included physicians (n=3), nurse practitioners (n=5), acupuncturists (n=3), researchers (n=3) and other health providers (n=6; pharmacist, psychotherapist, naturopath, physician assistant, health coach, and representative from funding organization). Workshop participants were primarily from the northeastern (38%) and mid-western (24%) US; however, 14% were from outside of the continental US.

Barriers to Sleep Health Interventions in Cancer Care

The pre-workshop survey indicated that 83.3% of survivors/advocates experienced insomnia symptoms at some point in their cancer experience, of which 58.3% did not receive treatment from their clinicians, and 25.0% received medication treatment for insomnia. Survivors reported that their clinicians rarely asked about sleep issues after a diagnosis of cancer (see Table 1).

Table 1.

Frequency of Clinician Inquiry About Sleep Issues After a Cancer Diagnosis

	Oncologist	Oncology Nurse	Primary Care Physician
Never	33.3%	58.3%	41.7%
Rarely	8.3%	0.0%	16.7%
Sometimes	16.7%	16.7%	16.7%
Often	16.7%	0.0%	8.3%
Always	0.0%	8.3%	0%
I don’t currently see this type of clinician	25%	16.7%	16.7%

The pre-conference workshop survey identified several key patient- and clinician-level barriers (see Table 2). Workshop participants used these initial survey results to further identify and describe barriers to dissemination and implementation of sleep health treatment options in cancer centers. The primary barriers identified during the workshop were: 1) lack of education about the importance of sleep health; 2) lack of awareness of the evidence for non-pharmacological treatment; 3) financial constraints (e.g. treatments not covered by insurance); 4) access and practical issues (e.g. lack of clinicians); and 5) existing attitudes and beliefs (e.g. medication is the only treatment available). We grouped these barriers into the following categories: patient, clinician, and institutional/societal (see Table 3).

Table 2.

Top Participant-perceived Patient and Clinician Barriers Associated with Use or Prescription of Non-medication Insomnia Treatments

Type	Barrier	% Agree “a lot”
Patient	Patients not aware that non-medication treatments such as CBT-I and acupuncture exist	75.0%
	Patients are aware but they find it difficult to access CBT-I or acupuncture because of cost/lack of insurance coverage	71.4%
	Taking medication is easier for patients than trying to change habits or going for insomnia treatment	57.1%
	Patients feel too emotional and/or cognitively overwhelmed with cancer-related issues other than sleep	42.9%
Clinician	Clinicians are already too busy and their limited time is already consumed by the need to address patients’ acute medical problems	64.3%
	Prescribing a medication is easier than discussing non-medication treatments	64.3%
	Clinicians are not aware of the evidence for non-medication-based treatments such as CBT-I and acupuncture	63.0%
	Clinicians are not aware that non-medication-based treatments such as CBT-I and acupuncture exist	60.7%
	Clinicians are aware but insurance will not reimburse for these treatments	59.3%
	Clinicians are aware but don’t know which treatment to refer patients to	55.6%

Table 3.

Patient, Clinician, and Institutional/Societal Barriers to Implementing Non-Pharmacological Sleep Health Treatments in Cancer Centers

Identified Barrier	Patient	Clinician	Institutional/Societal
Lack of awareness about the importance of sleep health	Patients are not aware of the important of sleep for overall health promotion and cancer recovery Patients may not make sleep discussions a priority during their doctor’s appointment	There is a lack of specific sleep health content during training or residency There may be competing patient priorities and sleep may be viewed as less important to address given multiple needs of patients	Sleep health may not be seen on same level of importance as chemotherapy, radiation, etc. Employers, family members, etc. may not support time away to address sleep health
Lack of awareness of evidence for non-pharmacological treatment	Patients may not be aware that effective non-medication treatments exist Patients may feel that medication is easier than trying to change habits or going for insomnia treatment	Clinicians may lack the knowledge to suggest non-pharmaceutical treatment options for sleep Clinicians may be uncomfortable, unable, or unwilling to talk with patients about non-pharmacological treatments	Institutions and the broader society may not be aware of evidence of efficacy
Financial Constraints	Patients may have to pay out of pocket and struggle to cover the cost of treatments	Cost and misinformation about out-of-pocket costs may create communication barriers	Institutions may not cover salaries for clinicians and insurance may not reimburse for these services Decision makers may prioritize the less expensive option in the short term
Access and Practical Issues	Patient may not able to find or access clinicians in their area Patients may feel additional time burden of seeing more doctors	Clinicians may lack the capacity to provide the services or may not have the ability to refer out to another clinician Lack of time within a clinic visit to explain available services	Shortage of clinicians/therapists to provide services Lack of space for treatments / space not prioritized for treatments
Existing Attitudes and Beliefs	Patient may experience cultural barriers because they don’t “See people like me” receiving these services	Clinicians may have a reactive approach to medicine – treatment rather than prevention Perception/stigma that some populations “already don’t sleep anyway” resulting in a lack of motivation to treat them	Sleep is not considered part of a holistic approach to health

Recommendations for Dissemination and Implementation

The resultant recommendations are intended to address the identified barriers and outline priorities and directions for dissemination and implementation with the ultimate goal of improved diagnosis and patient-centered insomnia management in cancer care, see Table 4. The CHOICE study and Sleeping Well After Cancer workshop provide a starting point for development of strategies for implementing CBT-I and acupuncture.

Table 4:

Recommendations to Improve Sleep Health in Cancer

Dissemination Recommendations

1. Increase awareness of the importance of sleep health for cancer recovery

2. Increase awareness of evidence for non-pharmacological treatment of insomnia and other sleep disturbances

3. Change attitudes and beliefs about the use of non-pharmacological interventions for sleep health

Implementation Recommendations

1. Address organizational barriers to the screening and identification of problems with sleep and the delivery and receipt of non-pharmacological interventions for sleep health

2. Increase access to Cognitive Behavioral Therapy for Insomnia in cancer settings

3. Increase access to acupuncture for symptom management in cancer settings

Dissemination Recommendations

1. Increase awareness of the importance of sleep health for cancer recovery

Workshop participants identified a lack of patient and clinician knowledge of the importance of sleep health as a barrier to patient access to insomnia treatment. This is consistent with a cross sectional survey of people with insomnia, in which the four most commonly endorsed reasons for not seeking treatment were: “I thought the difficulty with sleep was an expected response to a life situation,” “I thought it was something I should be strong enough to handle myself,” “I didn’t recognize the difficulty with sleep was an illness,” and “I thought the problem would get better by itself.”[37] Dissemination of information to patients, clinicians, institutions, and society on the importance of sleep health is a critical first step to effectively implement interventions to improve sleep in people who have experienced cancer.

2. Increase awareness of evidence for non-pharmacological treatment of insomnia and other sleep disturbances

Workshop participants felt that patients and providers were not well versed in the options available to manage insomnia and that preferences for insomnia treatment were influenced by their understanding of treatment options. Patient preferences are vulnerable to inaccurate information (e.g. a belief that acupuncture has a stronger evidence base because it has been practiced for a long time), misconceptions (e.g. believing that insomnia is a result of a chemical imbalance), and factors unrelated to the treatments themselves (e.g. one treatment is easier to access). [38] These factors can also influence physician decision-making, making it a priority to disseminate information to both patients and clinicians to facilitate patient-centered decision-making and care.

3. Change attitudes and beliefs about the use of non-pharmacological interventions for sleep health

Workshop participants believed that physicians still primarily recommend pharmacotherapies to treat insomnia and feel unprepared to guide their patients to non-pharmacologic treatments.[39] Lack of familiarity with CBT-I and/or acupuncture among patients and lack of clinician endorsement contribute substantially to diminished willingness to use these interventions. These findings point to the significant need for dissemination initiatives to increase knowledge of CBT-I and acupuncture among both patients and clinicians.

Implementation Recommendations

1. Address organizational barriers to the screening and identification of problems with sleep and the delivery and receipt of non-pharmacological interventions for sleep health

Workshop participants identified multiple capacity building needs including institutional capacity to screen for sleep problems, and clinicians’ ability to talk with patients about non-pharmacological sleep interventions, in addition to treatment costs and lack of insurance coverage as major obstacles, consistent with other research.[40] Without universal access for all via insurance or another means, though, access barriers remain, particularly for those with lower socio-economic status.

2. Increase access to Cognitive Behavioral Therapy for Insomnia in cancer settings

Workshop participants felt strongly that CBT-I should be available within cancer treatment settings. Psychologists, nurses, social workers, and other allied health professionals could all deliver CBT-I on the front lines with appropriate training. The Veterans Administration in the United States,[41] successfully implemented and evaluated a nationwide CBT-I treatment program.[42] This model could be used as a template at all NCI-designated Comprehensive Cancer Centers to increase access to the recommended evidence-based treatment for insomnia in people diagnosed with cancer.

3. Increase access to acupuncture for symptom management in cancer settings

Workshop participants also wanted acupuncture to be available within cancer treatment settings. Despite the growing evidence of acupuncture for cancer symptom management,[19] the limited availability of acupuncturists remains a barrier to implementation. Delivering acupuncture to the cancer population requires basic oncology knowledge to ensure safety and minimize risk of infections, bleeding, or other complications; specific training about cancer-related insomnia is essential to ensure high quality and effective treatment. In care settings that lack capacity for onsite acupuncture, development of referral networks and community clinic partnerships may be needed to address access barriers.

DISCUSSION

The Sleeping Well After Cancer workshop identified barriers to the identification and promotion of sleep health in cancer and generated a strategy for future translation and implementation of research into clinical practice. One major theme is the need to increase awareness of the importance of sleep health in cancer. Many clinicians and patients may not recognize insomnia as a serious condition, often considering it merely a symptom secondary to another condition.[43] In a qualitative study of physicians and patients with insomnia, difficulty sleeping was more often attributed to another issue such as depression, a stressful everyday problem, or the natural life process of aging [44] and was not necessarily linked to daytime impairment. Dissemination efforts to increase awareness of sleep health in other populations have been successful and have include brief provider sleep training, social media awareness campaigns about the availability of non-drug treatments, and patient education to reduce stigma of seeking help for insomnia.[45] Collaboration with experts in marketing or behavioral economics and/or research on how best to educate clinicians and cancer survivors about insomnia and sleep health is needed to change behavior in order to prioritize sleep during clinical visits, prompt patients to discuss their sleep, and increase referrals to appropriate treatments.

In addition to a lack of awareness of the importance of sleep health, lack of knowledge about and inaccurate beliefs about the effectiveness of nonpharmacological treatments were identified in the workshop as additional barriers. Patients and clinicians are relatively unaware of the efficacy of non-pharmacological insomnia treatments in people diagnosed with cancer despite their inclusion in clinical guidelines[46, 47]. In a study of nearly 1,000 physicians, 47% perceived non-pharmacologic approaches to be too time-consuming, and 55% felt the treatment would be too expensive for the patient and that motivating the patient would be too difficult.[48] One in four (24%) physicians thought patients would not feel their concerns were taken seriously if they did not receive prescriptions. However, these concerns are not consistent with research on patient views of non-pharmacological interventions. In an epidemiological study of adults who reported current or past use of sleeping medication, 80% indicated that they would prefer nonpharmacological treatment, but only 10% had been offered it. [49] Eliminating this gap between patient and provider views of these treatments may be one strategy for improving access to these treatments. Proactive patient outreach and informational campaigns that emphasize the widespread benefits of improving sleep are previously used strategies that may improve dissemination and implementation of insomnia treatments.[50] The use of peer champions and testimonials have also been identified as potential ways to engage with patients who may be hesitant to engage in treatment. [50]

Successful implementation of CBT-I and acupuncture is as important as the effectiveness of these treatments. Dissemination and implementation of sleep and circadian science [51] and evidence-based interventions for sleep is an international challenge.[52] Specific to dissemination and implementation in cancer, a review of dissemination and implementation research grants funded by the National Cancer Institute between 2006 and 2019 identified that only 11 out of 71 grants were focused on cancer survivorship.[53] Implementation research is needed to address systemic barriers to receiving nonpharmacological interventions for insomnia in cancer settings. The first implementation barrier relates to systemic challenges in the identification, delivery, and receipt of non-pharmacological interventions for sleep health. Screening for sleep problems is recommended in current survivorship guidelines [24, 47, 54] and can be accomplished with existing tools (i.e., the Edmonton Symptom Assessment Scale [55]). In addition to screening, there have also been recommendations to implement sleep interventions using a stepped care model to ensure cost efficacy[47, 56–58], but this implementation process has yet to be formally evaluated in a cancer setting (although an efficacy trial is currently underway: https://clinicaltrials.gov/ct2/show/NCT01864720).

Ultimately, access to treatment will remain a barrier until there is coverage for all via insurance or another means. CBT-I services delivered by mental health clinicians are available at some settings and/or covered by some insurance plans. An increasing number of private health insurance companies cover acupuncture for various conditions;[59] however, gaps in coverage remain. A long-term solution is to change policy to improve insurance coverage for CBT-I and acupuncture. In the meantime, there are short-term and organization-specific factors that can promote sustainment including leadership support and allocation of resources for provision of CBT-I and acupuncture. This may begin with the identification of existing infrastructure that can be leveraged to deliver CBT-I and acupuncture within cancer care settings to promote maintenance and sustainability of these interventions over time. The use of technology may facilitate the screening, diagnosis, and referral process to promote the implementation of guidelines and provision of evidence-based intervention. Adaptations to CBT-I and acupuncture may be considered for particular settings with evidence suggesting comparable intervention effectiveness for more feasible and scalable delivery models (e.g. acupuncture delivered to groups,[60, 61] CBT-I delivered by telehealth,[62] over the telephone,[63, 64] and by mobile applications with or without clinician support[65]).

A dearth of providers trained in sleep interventions is an additional barrier to widespread dissemination and implementation. [45, 51, 52] To increase to the pool of qualified CBT-I clinicians, the Society for Behavioral Sleep Medicine established the Diplomat in Behavioral Sleep Medicine (DBSM) designation intended to standardize the credentialing of CBT-I providers. [66] The European Sleep Research Society also intends to develop a European CBT-I academy to enable CBT-I training and training center accreditation. [52] More work also needs to be done to increase access to acupuncturists with cancer-specific training. Over half of licensed acupuncturists in the United States practice in New York, California, and Florida, with the majority concentrated in upper-income neighborhoods,[67, 68] hindering access for cancer patients from socio-economically disadvantaged backgrounds and/or non-coast regions. The well-documented paucity of communication between acupuncturists and conventional clinicians also presents challenges for implementation, hampering care coordination and acupuncture referrals.[69] Inter-professional training initiatives, informed by team science, are essential to promote better integration of acupuncturists with the rest of the multidisciplinary oncology team.[70]

Much can be learned from existing attempts to disseminate and implement non-pharmacological sleep interventions at the patient, provider and organizational levels. The successful dissemination and implementation of CBT-I within the Veterans Administration in the United States provides insight into potentially effective strategies for other settings including 1) engagement of sleep champions, (2) eliciting support from opinion leaders, and 3) for services to be integrated within existing clinical care and the referral pathways well-defined. [71] One particularly promising recommendation was to link the referral to non-pharmacological sleep treatments to various deprescribing initiatives as a way to provide an external incentive and quantify the value of these services. While each setting will need to consider specific contextual factors that will impact these implementation strategies, this prior work provides a starting point for improving patient access to non-pharmacological sleep interventions. Factors to consider include but are not limited to relevant federal legislation, the organization’s size, and readiness to change regarding services provided. Lastly, administrative issues (e.g. hospital credentialing) and logistical considerations (space, scheduling, and staffing) will need to be addressed to enhance delivery capacity.

Organizations may also benefit from establishing community partnerships with qualified clinicians to address implementation barriers. The creation and use of inter-organizational networks to share information and training and/or hiring of clinicians could enable and enhance the delivery CBT-I and acupuncture. Potential resources for inter-organizational network development related to CBT-I and acupuncture include the Society for Behavioral Sleep Medicine, the American Society for Clinical Oncology, the Society for Integrative Oncology and the Society for Acupuncture Research.

Ultimately, the goals of conducting research are to generate evidence that translates into clinical practice to benefit patients. With dedicated effort and resources, through dissemination and implementation, we have the opportunity to improve patient-centered insomnia treatment for millions of people who have experienced cancer.

Data Availability:

Data sharing not applicable to this article as no datasets were generated or analysed during the current study