Insomnia Linked to High Symptom Burden in Women With Breast Cancer in Rural Areas

There is a direct relationship between insomnia severity and symptoms of fatigue, depression, and pain among women with breast cancer from medically underserved areas. These findings were recently published in Behavioral Sleep Medicine.

Women with breast cancer commonly experience insomnia, which is linked to symptoms of fatigue, depression, and pain. However, research examining these symptoms among individuals living in medically underserved areas is limited.

To address this gap, researchers analyzed data from a behavioral pain intervention trial for women with breast cancer and pain in rural, medically underserved areas. They aimed to assess symptom severity, compare symptoms across insomnia severity categories, and explore variations based on demographics.

Eligible adult women with Stage 0-IV breast cancer were enrolled if they reported pain for at least 10 days in the past month with a severity rating of 4 out of 10 or higher. A total of 127 women completed questionnaires assessing insomnia, fatigue, depression, and pain. Participants were a mean (SD) age of 60.5 (12.5) years, 59.8% were White, 41.3% had some college education, 24.6% had a pre-tax income between $40,000 and $59,000, and 52.0% were married. For 91% of participants, this was their first breast cancer diagnosis.

Median insomnia severity was in the subthreshold/mild range (12.0; IQR, 6.00-16.00), with 32% of participants reporting no insomnia, 34% reporting subthreshold/mild, 28% reporting moderate, and 6% reporting severe. Median depressive symptoms (17.0; IQR, 10.50-23.50) indicated risk for clinical depression, while median fatigue (60.80; IQR, 55.60-64.85), mean (SD) pain severity (4.6 [1.9]), and median pain interference (4.29; IQR, 2.57-6.46) were moderate. Greater insomnia severity was associated with worse overall symptom burden.

ANOVA and Kruskal-Wallis tests showed that participants with subthreshold/mild or moderate/severe insomnia reported greater fatigue, more depressive symptoms, and higher pain interference compared with those without insomnia (all P <.0001). Participants with moderate/severe insomnia also reported more severe pain than those with no insomnia (P =.004).

Post-hoc linear regression analyses treating insomnia as a continuous variable confirmed that insomnia significantly predicted fatigue, depressive symptoms, and pain interference (all P <.0001), as well as pain severity (P =.008). Residual analyses indicated a linear association between insomnia and depressive symptoms, whereas relationships with fatigue and pain appeared non-linear.

Further, younger women (≤60 years) reported worse insomnia severity (P =.048), fatigue (P =.03), depressive symptoms (P =.0005), and pain interference (P =.0003) compared with those aged 60 years and older, though pain severity did not differ by age. In contrast, sociodemographic factors such as race, education, and income were associated only with pain severity. Non-White women reported greater pain severity than White women (P <.0001). Women with a high school education or less reported more pain severity than those with higher education (P =.004), and women with annual incomes below $20,000 reported more pain severity than those with higher incomes (P =.0003).

Partnership status was not associated with most symptoms, although unpartnered women reported greater depressive symptoms than partnered women (P =.04). Symptom severity did not vary by cancer stage.

Study limitations included reliance on self-reported assessments, a cross-sectional design, and a small sample size.

“[T]hese findings highlight several distinct symptoms (eg, insomnia, fatigue, depression, pain) that comprise a high symptom burden continuing past initial diagnosis and primary treatment for unique sample of women with breast cancer from rural, medically underserved areas,” the study authors concluded.