The assessment, identification and management of Circadian rest-Activity Rhythm Disorders in patients with advanced Cancer (CARDiC)

Abstract

People with cancer may experience restless nights and be less physically active during the daytime. People with cancer may also find that the amount of time they spend being physically active or resting changes a lot between days. Research has found a link whereby people with these changes in their rest and physical activity tend to have more worse symptoms, poorer quality of life and a shorter lifespan. However, it was unclear how common the problem was and who tends to get it. There was also no agreed way of diagnosing the problem, or of treating it. The purpose of this research project was to provide some answers to these questions. At first, a group of experts created a standard way to assess and report on people's daytime and nighttime levels of rest and physical activity, and a way to diagnose people who have a problem in these patterns. A set of questions, created to identify people that are at risk of unusual rest and physical activity patterns, failed to recognise those people. However, a study did show that up to 60% of people with advanced cancer have a problem with their rest and physical activity patterns. The study showed that people with more severe disease and those who are less able to carry out their daily activities are examples of factors associated with the problem. People with the problem are also likely to have more symptoms, including feeling more tired and drowsy, have more distress from their symptoms, poorer quality of life and are less able to function as well as they would like. A second study aimed to improve the rest and physical activity patterns of people with advanced cancer, using a sleep course, daily light therapy, and a personalised activity plan. People felt able, and happy to, take part in the study and early data suggests potential benefits in improving people's activity patterns, symptoms and quality of life. SCIENTIFIC ABSTRACT In health, people demonstrate a circadian, or 24-hour, physical activity pattern with more physical activity in the day and less physical activity at night. A sub cohort of patients with cancer experience nighttime restlessness and daytime sedentariness, altered physical activity spread across the 24-hour period, or a significant change in activity patterns between days. These changes are more likely in advanced cancer. When this occurs, research highlights that patients have increased symptoms, worse quality of life and a shorter survival. An international e-Delphi study has identified important features of circadian rest-activity rhythm disorders (CARDs), including diagnostic criteria, and standardised assessment methodology. An observational study failed to demonstrate validity of a related screening tool to detect circadian rest-activity rhythm disorders. However, the study highlighted CARDs to be common (60%) and several patient-related factors associated with circadian rest-activity disruption including metastatic organ involvement and higher inflammatory status, for example. It also highlighted significant associations with a CARD diagnosis and increased symptom burden, including fatigue and daytime sleepiness, increased symptom-related distress, poorer global quality of life and poorer functioning subscales. A subsequent feasibility study has proven the acceptability, usability and preliminary efficacy of a multimodal non-pharmacological intervention consisting of cognitive behavioural therapy - insomnia (CBT-I), bright light therapy, and a personalised activity plan. Improvements were seen in important clinical outcomes (symptoms and quality of life measures) and circadian rest-activity rhythm parameters (dichotomy index and 24-hour autocorrelation coefficient).