Quality of Sleep Among Newly Diagnosed Head and Neck Cancer Patients at Vietnam National Cancer Hospital: A Single Center Observation Study
Article information
Abstract
Background and Objective
Sleep disturbances are prevalent among cancer patients, particularly those with head and neck cancer (HNC). The present study aimed to assess the prevalence and factors contributing to poor sleep quality in HNC patients receiving treatment at the National Cancer Hospital in Vietnam.
Methods
A cross-sectional study was conducted on 202 newly diagnosed HNC patients between January 2023 and December 2023. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI), with a score greater than 5 indicating poor sleep quality. Factors such as cancer stage, treatment type, pain, and socioeconomic status were analyzed for their association with sleep quality.
Results
Among 202 patients, 152 (75.2%) had poor sleep quality before treatment. Several factors were found to be significantly associated with poor sleep: younger age, being female, having swallowing problems, and taking painkiller.
Conclusions
Poor sleep quality is highly prevalent among HNC patients prior to the initiation of treatment. Early evaluation and tailored interventions to improve sleep quality are crucial in preparing these patients for the challenges of HNC treatment and its associated consequences. Addressing sleep disturbances at an early stage can enhance patients’ overall well-being, improve treatment outcomes, and mitigate the physical and psychological stressors associated with cancer care.
INTRODUCTION
Head and neck cancer (HNC) encompasses a diverse group of malignancies that arise in the upper aerodigestive tract, including the oral cavity, pharynx, larynx, and associated structures. According to data from GLOBOCAN 2020, HNC constitutes approximately 5% of all cases, with over 930,000 new cases and more than 460,000 deaths globally. In Viet Nam, more than 10,000 new cases of head and neck were diagnosed HNC according to GLOBOCAN 2020 [1]. There is a growing attention to maximize health-related quality of life of newly diagnosis HNC patients. These patients often suffer from emotional distress and concerns related to the future consequences of HNC itself and its treatment, which may affect their sleep quality [2]. In addition, poor sleep quality also has a detrimental impact on treatment effectiveness, diminishes the quality of life, and extends the treatment duration, further compounding financial challenges for both the patient and their family. The issue of assessing sleep quality in HNC patients has not been given sufficient attention and is often overlooked. According to Santoso et al. [3], there are 44% of HNC patients had poor sleep quality before the start of treatment. Several other studies using the Pittsburgh Sleep Quality Index (PSQI) scale to assess sleep quality also indicate that 37% of patients in their studies had poor sleep quality [4,5]. Understanding the inadequate sleep quality in HNC patients can assist healthcare professionals in developing more effective sleep interventions for patients during treatment.
METHODS
In the study, 202 newly diagnosed HNC patients in National Cancer Hospital were included between January 2023 and December 2023. Inclusion criteria were as follows: newly diagnosed with squamous cell of nasopharyngeal, oral cavity, oropharynx, hypopharynx, larynx, or neck lymph node metastasis of unknown primary tumor; being 18 years old or older. Excluded criteria: having severe psychiatric comorbidity, patients who are unable to communicate cannot respond to the question.
Measure
In this study, data were collected shortly after the diagnosis and prior to the initiation of cancer treatment. Sleep quality was assessed using the PSQI, which was completed by the patients themselves. This self-reporting method allowed for a comprehensive evaluation of each patient’s sleep quality and provided valuable insights into their sleep patterns and difficulties during this critical period [6]. PSQI consists of 19 items across seven components of sleep quality and disturbances: 1) subjective sleep quality (i.e., one item “How would you rate your sleep quality overall?”), 2) sleep onset latency (i.e., two items asking time needed to fall asleep and its frequency in a week; poor sleep onset is defined as needing ≥30 minutes to fall asleep), 3) sleep duration (i.e., one item “How many hours of actual sleep do you get at night?”; ≤6 hours is associated with worse survival among cancer patients), 4) sleep efficiency (i.e., a percentage calculated by dividing time asleep by time spent in bed and multiplied by 100; <85% indicates poor efficiency), 5) sleep disturbances (i.e., 10 items about specific reasons for the sleep disturbances and their frequency), 6) use of sleep medication (i.e., one item “How often have you taken medicine to help you sleep?”), and 7) daytime dysfunction (i.e., two items asking the frequency of staying awake during daytime activity and the extent of difficulty to maintain enthusiasm to get things done) [6]. A total score (also called global score) is calculated by first scaling each component score into a 0 to 3 score, then summing all component scores, resulting in a score ranging from 0 to 21; higher scores indicate worse sleep quality. Our main outcome, poor sleep quality, is defined by a total PSQI score of >5 [7].
Study Process
Step 1: Select patients according to inclusion criteria and exclusion criteria.
Step 2: Before treatment, collect patient information from medical records, examine the patient, and ask the patient’s family members to exploit all the personal characteristics, social characteristics, clinical symptoms, disease stage, and previous history of the patient.
Step 3: Ask the patient directly to gather the most detailed and precise information regarding their sleep issue on the PSQI scale.
Step 4: Gather and analyze the data that has been gathered to identify relevant variables that achieve study goals. Utilizing a standardized process and methodology, recording forms, and processing data.
Statistical Analysis
Data collected will be entered into SPSS software (version 20.0, IBM Corp.). Descriptive statistics will be used to summarize demographic and clinical characteristics. The prevalence of sleep disorders will be calculated, and factors associated with sleep disturbances will be analyzed using appropriate statistical tests such as chi-square or t-tests.
Research Ethics
This study was reviewed by the Institutional Review Board of Vietnam National Cancer Hospital and was determined to be exempt from the requirement for formal ethics approval in accordance with local regulations. As this was an exempt review, no IRB number or file code was issued. The study is descriptive and observational, does not involve any intervention, and does not affect patient treatment outcomes. All patient information was kept confidential, written informed consent was obtained, and the study was conducted in compliance with the Declaration of Helsinki.
RESULTS
Study Population
Our study data consisted predominantly of men (75.7%), with an average age of 55.45 years (standard deviation [SD]=11.30). Most patients were married (89.6%), and a significant proportion had lower levels of education (88.1%). Additionally, most participants lived in rural areas (71.8%) and reported low income (66.8%) (Table 1). In terms of cancer types, nasopharyngeal and hypopharyngeal cancers represented the largest proportion of patients, accounting for 44.1% and 25.7%, respectively. Additionally, 18.8% of patients had comorbidities (including hypertension, diabetes, chronic obstructive pulmonary disease, etc.). More than half of the patients required painkillers prior to the start of treatment. Head and neck symptoms, such as oral pain and swallowing problems, were reported by 14.4% and 30.7% of the patients, respectively. These symptoms highlight the significant burden of the disease even before treatment begins (Table 2).
Sociodemographic characteristics of the sample
Characteristics of cancer disease
Sleep Quality
According to Table 3, among the 202 HNC patients, 75.2% were classified as having poor sleep, as indicated by a PSQI score greater than 5. The mean sleep duration for these patients was 6 hours (SD=1). Notably, 32.2% of the patients reported sleeping less than 5 hours per night, and 65.3% exhibited sleep efficacy of less than 85%. Additionally, a small number of patients (5.0%) required support from sleep medications to manage their sleep issues.
Sleep characteristics of patients
Factors Associated with Poor Sleep Quality
Univariate analyses revealed that patients with poor sleep (n= 202) were more often younger, women, using painkiller and having swallowing problems (Table 4).
Comparisons of patients with good sleep versus patients with poor sleep
Multivariate logistic regression models demonstrated that poor sleep is significantly associated with sociodemographic factors (young age, being female) and HNC symptoms (using painkiller, having swallowing problems). Combining all of these significant variables in a logistic regression model, we found that younger age (odds ratio [OR]=0.47, 95% confidence interval [CI]=0.3–0.8, p=0.024), being female (OR=2.73, 95% CI=1.6–4.3, p=0.037), used painkiller (OR=3.21, 95% CI=1.4–4.8, p<0.001), and having swallowing problems (OR=2.41, 95% CI=1.1–3.9, p=0.033) was associated with an increased likelihood of experiencing poor sleep (Table 5).
The final model of the multivariable logistic regression analysis with poor sleep (PSQI total score >5) as the outcome (n=202)
DISCUSSION
With the increasing number of people with HNC over the past few decades, the focus in this population has shifted from survival to a better quality of life. In this study, we explored the occurrence of poor sleep quality in HNC patients prior to the initiation of treatment and analyzed the factors related to it. By utilizing the PSQI, approximately 75.2% of patients in this study exhibited poor sleep quality. Compared to the general population, which has a prevalence rate of 36%, this figure is significantly higher [7]. In addition, Abebe et al. [8] studied in 264 adult cancer patients showed that the percentage of poor sleep quality patients (defined by PSQI >5) was 53.79%. Our results show a higher prevalence of poor sleep quality (75.2%) compared to previous studies by Santoso et al. [3] (44%) and Mo et al. [4] (37%). The inconsistency might be due to the previous studies’ participants’ educational status; even the income and life status difference of the study participants might have an impact on the outcome of the result.
We found that younger age, being female, having swallowing problems, and taking painkiller were the most significant factors related to poor sleep. In general population, total sleep time, sleep efficiency, and deep sleep (slow wave sleep) decrease with aging; and number of nocturnal awakenings and time spent awake during the night increase with aging [9]. In contrast, in our study, HNC younger cancer patients are more likely to have worse sleep than elderly patients. Our result is consistent with the results of prior studies conducted on HNC patients in the pre-treatment phase [10]. This may be explained by the fact that being diagnosed with cancer at a younger age is associated with greater psychological distress, including factors such as a decrease in income, negative changes in work or school, and fear of disease progression, compared to older individuals.
Hinz et al. [7], in a study of 550,000 inhabitants in Germany, found that females tended to experience more sleep problems than males. This is consistent with the findings from our study conducted among HNC patients prior to treatment. The increased likelihood of sleep disturbances among women can be attributed to a confluence of physiological and psychological factors. Hormonal fluctuations related to menstrual cycles, pregnancy, and menopause may adversely affect sleep patterns, as the interplay of estrogen and progesterone influences sleep architecture and quality. Furthermore, psychological stressors, including heightened rates of anxiety and depression among women, are known to exacerbate sleep disturbances. These emotional and psychological factors can significantly interfere with sleep quality, potentially leading to a vicious cycle where poor sleep further exacerbates psychological distress. Whether sex differences in sleep quality can be entirely attributed to depressive symptoms remains an open question, as research indicates that depressive symptoms impact sleep quality differently in men and women [11]. Additional research is necessary to evaluate the intricate connection between depressive symptoms and sleep quality in both male and female individuals with HNC.
Several studies have demonstrated that swallowing problems, such as dysphagia, can negatively impact the quality of sleep in patients [12]. In our study, the incidence of oropharyngeal cancer, oral cavity cancer, and hypopharyngeal cancer is relatively high, which consequently leads to a significant prevalence of swallowing problems among patients (30.7%). Dysphagia not only affects the ability to consume food and fluids but can also lead to increased anxiety and discomfort during the night, further disrupting sleep patterns. Additionally, patients experiencing swallowing difficulties may have altered eating habits, which can affect nutritional intake and overall health, exacerbating fatigue and stress levels. The relationship between dysphagia and sleep disturbances highlights the need for comprehensive management strategies that address both swallowing difficulties and their impact on sleep. Implementing supportive therapies, such as nutritional counseling and swallowing rehabilitation, may help mitigate these issues and improve overall quality of life for patients with HNCs [13].
We found that sleep quality prior to HNC treatment is significantly associated with the use of painkillers. This relationship suggests that patients who are using pain management strategies may experience different sleep outcomes compared to those who are not. Specifically, the effective management of pain using analgesics can lead to improvements in sleep quality, enabling patients to achieve more restorative sleep. Conversely, the side effects associated with certain painkillers, particularly opioids, may also disrupt sleep architecture. Additionally, it is understandable that patients using painkillers, who experience multiple symptoms of HNC (such as oral pain and difficulty swallowing), tend to have poorer sleep quality compared to those who do not use painkillers.
In conclusion, low sleep quality is common among patients recently diagnosed with HNC and is linked to factors such as being younger, female, having swallowing problems, taking painkiller. Our results emphasize the importance of conducting early sleep assessments in HNC patients prior to the initiation of treatment. Additionally, it is crucial to consider HNC symptoms when implementing sleep interventions.
Notes
Availability of Data and Material
The datasets generated or analyzed during the study are available from the corresponding author on reasonable request.
Author Contributions
Conceptualization: Dang Nguyen Van. Data curation: Luc Tieu Van, Trang Nguyen Thi. Formal analysis: Luc Tieu Van. Methodology: Dang Nguyen Van. Validation: Dang Nguyen Van. Supervision: Dang Nguyen Van. Validation: Luc Tieu Van, Dang Nguyen Van. Visualization: Luc Tieu Van. Writing—original draft: Luc Tieu Van. Writing—review & editing: all authors.
Conflicts of Interest
The authors have no potential conflicts of interest to disclose.
Funding Statement
None
Acknowledgements
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