Cognitive Behavior Therapy, Acupuncture Improve Insomnia Symptoms in Cancer Survivors


Both cognitive behavior therapy for insomnia (CBT-I) and acupuncture produced clinically meaningful improvements in insomnia severity scores for cancer survivors, but data from the randomized CHOICE clinical trial showed that CBT-I was more effective overall for reducing the severity of insomnia.

Jun J. Mao, MD

Both cognitive behavior therapy for insomnia (CBT-I) and acupuncture produced clinically meaningful improvements in insomnia severity scores for cancer survivors, but data from the randomized CHOICE clinical trial showed that CBT-I was more effective overall for reducing the severity of insomnia.

In results presented ahead of the 2018 ASCO Annual Meeting, Insomnia Severity Index (ISI) scores declined by 10.9 points (95% CI, 9.8-12.0) during treatment for those assigned to CBT-I, from 18.5 to 7.5. Participants assigned to acupuncture saw their ISI scores decline by 8.3 points (95% CI, 7.3-9.4), from 17.5 to 9.2.1 Improvements were maintained for up to 20 weeks following the start of the trial, even after completion of treatment.

“Our hope is that by doing this type of research, we can help patients and clinicians pick the right kind of treatment for them to manage their sleep,” said lead study author Jun J. Mao, MD, chief, Integrative Medicine Service, Memorial Sloan Kettering Cancer Center in New York.

“Our next step is to examine for what type of patients [each] treatment may be beneficial, and how to deliver this type of effective treatment to broader communities of cancer patients,” he added.

Response rates at the end of treatment were significantly higher for CBT-I in participants with mild insomnia compared with acupuncture (n = 33; 85% vs 18%; P <.0001). Response rates were similar in those with moderate-to-severe insomnia (n = 127; 75% vs 66%; P = .26).

Adverse events were mild in both groups. Additionally, improvements in quality of life for physical health (P = .4) and mental health (P = .36) were similar in both groups.

ASCO President Bruce E. Johnson, MD, commented during the presscast that these results can help clinicians choose how to best address a patient’s insomnia. He added that insomnia severity could influence the choice of treatment.

“The most common way we treat [insomnia] is pharmacologically with sleeping pills,” he said. “This shows that using 2 different methods other than medications can help people with sleep and, not only help with sleep, but improve their quality of life.”

Up to 60% of cancer survivors have some form of insomnia, but the condition is often underdiagnosed and undertreated. Results from a previous study published in the British Journal of Cancer suggested that survivors of breast cancer who had regular sleep difficulties could be at increased risk for all-cause mortality.2

CBT-I is a form of psychotherapy designed to change a patient’s sleep-related thoughts, emotions, and behaviors. Mao called it “the gold standard” for insomnia treatment, but adherence is often poor and it is a highly specialized therapy that is not available in many cancer centers.

Mao said that, over the past 10 years, functional brain imaging studies have shown that acupuncture can regulate the regions of the brain that are responsible for cognition and emotion, which are critical for sleep function. Moreover, acupuncture is available at 73% of comprehensive cancer centers in the United States.

Survey results have shown that survivors prefer nonpharmacologic solutions to their sleep problems, and the research team worked with a panel of patient advisors to select acupuncture as a comparator for CBT-I in this trial.

Mao et al recruited 160 survivors with clinically diagnosed insomnia, all of whom had completed cancer treatment. Participants underwent 8 weeks of treatment with CBT-I (n = 80) or acupuncture (n = 80), and were reassessed after 12 weeks without treatment.

Insomnia severity was assessed on the ISI, a 28-point questionnaire that asks participants to rate the severity of their insomnia and to assess the effect that insomnia has on their quality of life and daily functioning. Patients with scores of 0 to 7 were considered not to have clinically significant insomnia, scores of 8 to 14 indicated mild insomnia, 15 to 21 showed moderate insomnia, and a score of 22 to 28 demonstrated severe insomnia.

Participants were a mean of 6 years postdiagnosis and had been treated for a variety of cancers, most often breast (31%) or prostate (23%). Six percent of participants had been treated for more than 1 type of cancer.

Mean participant age was 61.5 years. Women made up 57% of the cohort and 29.4% of participants were non-white. Seventy-nine percent of participants had moderate-to-severe insomnia while the rest reported mild insomnia.

Participants in the CBT-I arm went through cognitive restructuring, education, relaxation training, sleep restriction, and stimulus control. They were trained to reduce the amount of time spent in bed, and to only use their beds for sleep and sexual activity.

Participants were also taught good sleep hygiene including avoiding late-night snacking, avoiding light from cellphone and tablet screens, and setting a regular sleep schedule.


  1. Mao JJ, Xie S, Duhamel K, et al. The effect of acupuncture versus cognitive behavior therapy on insomnia in cancer survivors: a randomized clinical trial. J Clin Oncol. 2018;36(suppl; abstr 10001).
  2. Trudel-Fitzgerald C, Zhou ES, Poole EM, et al. Sleep and survival among women with breast cancer: 30 years of follow-up within the Nurses' Health Study. Br J Cancer. 2018;118(6):e6. doi: 10.1038/bjc.2017.437.

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