Sleep Medicine 12 (2011) 584–590

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Sleep Medicine
journal homepage: www.elsevier.com/locate/sleep

Original Article

Arm/shoulder problems and insomnia symptoms in breast cancer survivors:

Cross-sectional, controlled and longitudinal observations
Alv A. Dahl a,⇑, Inger-Lise Nesvold a,b,c, Kristin Valborg Reinertsen a,d, Sophie D. Fosså a
a
National Resource Center for Late Effects, Department of Oncology, Oslo University Hospital and University of Oslo, 0310 Oslo, Norway
b
Division of Rehabilitation-Physiotherapy, The Norwegian Radium Hospital, Oslo University Hospital, Rikshospitalet, 0310 Oslo, Norway
c
National Resource Centre for Women’s Health, Oslo University Hospital, Rikshospitalet, 0027 Oslo, Norway
d
The Cancer Centre, Oslo University Hospital, Ullevaal, 0407 Oslo, Norway

a r t i c l e i n f o a b s t r a c t

Article history: Objective: In breast cancer survivors (BCSs) the relation between insomnia symptoms and arm/shoulder
Received 31 August 2010 problems has hardly been investigated. In cross-sectional and longitudinal designs we examined this
Received in revised form 22 December 2010 association in BCSs and in comparison to age-matched controls from the general population.
Accepted 10 January 2011
Methods: Our cross-sectional sample consisted of 337 BCSs stage II/III studied in 2004 at a median of
3.9 years after surgery combined with adjuvant radiotherapy and cytostatics/hormones. In 2007 248
(74%) BCSs were re-examined (median 2.5 years later). The responses of the 2004 sample were compared
Keywords:
to those of 1685 controls.
Breast cancer
Insomnia symptoms
Results: Thirty percent of BCSs reported insomnia symptoms in 2004, and arm/shoulder problems were
Arm/shoulder pain significantly associated with insomnia, as were established variables in bivariate analyses. In 2004 only
Lymphedema regular use of hypnotics remained associated with insomnia in multivariate analysis. In bivariate analysis
Restricted shoulder mobility arm/shoulder pain and restricted mobility in 2004 were significant predictors of insomnia in 2007. Only
HUNT-2 insomnia in 2004 was a significant predictor in multivariate analysis. In bivariate analyses BCSs and con-
trols had several common factors associated with insomnia, but only regular use of hypnotics was com-
mon in multivariate analysis.
Conclusions: Arm/shoulder problems are factors to consider in BCSs with insomnia, particularly arm/
shoulder pain. Factors associated with insomnia in BCSs and general population controls are partially
overlapping.
Ó 2011 Elsevier B.V. All rights reserved.

1. Introduction
Arm/shoulder pain, arm lymphedema and restricted shoulder
mobility are common adverse effects in breast cancer survivors
(BCSs). At 5-year follow-up the prevalence of arm/shoulder pain
is 30–40%, of lymphedema 10–15%, and of restricted mobility
15–30% among BCSs who had axillary dissection [1–6]. Montazeri,
in an extensive review of QoL studies in BCSs, found that such arm/
shoulder problems were among the most common adverse effects
in BCSs with a considerable negative impact on their QoL [7].
An accepted definition of insomnia symptoms is ‘‘the predomi-
nant complaint of difficulty initiating or maintaining sleep or non-
restorative sleep for at least one month’’ [8]. Insomnia symptoms
(=insomnia from here on) are common in BCSs and associated with
reduced quality of life (QoL) [9,10]. Several risk factors have been
identified for insomnia in BCSs such as stage and treatment of
⇑ Corresponding author. Address: Oslo University Hospital, The Norwegian
Radium Hospital, P.O. Box 4953 Nydalen, 0424 Oslo, Norway. Tel.: +47 2293550;
fax: +47 22934553.
E-mail address: a.a.dahl@imbv.uio.no (A.A. Dahl).
the cancer, poor physical and mental health, vasomotor symptoms,
fatigue, being widowed or divorced and low level of education [11].
However, many of these risk factors for insomnia, like fatigue, anx-
iety and depression, are also observed in women of the general
population [12]. The same is true with pain, but the studies report
on pain in general rather than on specific arm/shoulder pain com-
monly observed in BCSs [11–13]. Therefore systematic knowledge
on the associations between arm/shoulder problems and insomnia
in BCSs, eventually adjusted for fatigue, anxiety, depression and
use of hypnotics, would add new knowledge.
Our group had the opportunity to analyze such data in a sample
of Norwegian BCSs examined twice with a questionnaire at a mean
of four (2004) and seven (2007) years after diagnosis. A consider-
able part of the questionnaire was also filled in by the female par-
ticipants of the population-based Health Survey of Nord-Trøndelag
County 1995–97 (HUNT-2) [14]. Access to this dataset allowed us
to make comparisons between BCSs and cancer-free controls from
the general population concerning insomnia and factors associated
with insomnia. On this basis we investigated the following
research questions: (1) What are the associations between arm/
shoulder problems (ASPs) and insomnia in BCSs in the cross-

1389-9457/$ - see front matter Ó 2011 Elsevier B.V. All rights reserved.
doi:10.1016/j.sleep.2011.01.011
 A.A. Dahl et al. / Sleep Medicine 12 (2011) 584–590
sectional 2004 sample? (2) Are ASPs measured in 2004 significant
predictors of insomnia in 2007 (longitudinal sub-sample)? (3)
What are the differences between BCSs of the cross-sectional
2004 sample and age-matched controls concerning insomnia and
arm/shoulder pain? (4) Are the factors associated with insomnia
in BCSs of the cross-sectional 2004 sample the same as among
the controls?
2. Materials and methods
2.1. Patients and controls
BCSs treated with postoperative locoregional radiotherapy for
stage II–III breast cancer during 1998 to 2002 at the Norwegian Ra-
dium Hospital (NRH) were first surveyed in 2004. The eligibility
criteria for the survey and the sampling of patients have been de-
scribed previously [15]. Among the 415 BCSs who fulfilled the
inclusion criteria, 23 (6%) declined to participate, and 43 (10%)
did not respond, resulting in 349 BCSs (84% response rate) answer-
ing the questionnaire in 2004 among whom 337 tumor-free BCSs
delivered valid data and comprised our cross-sectional (2004) sam-
ple. Among them 318 (94%) BCSs had a clinical examination that
year.
A follow-up survey took place in 2007, inviting 310 of the pre-
vious 318 BCSs to take part since we knew that 8 were dead or had
relapsed since 2004. The 248 of 310 (80%) BCSs who delivered a va-
lid questionnaire in both 2004 and 2007 comprised our longitudi-
nal sub-sample.
HUNT-2 invited all adults aged 20 years (N = 92,936) living in
Nord-Trøndelag County to take part (14, http://www.ntnu.no/dmf/
hunt/). Among them were 39,028 women aged from 25 to 79 years,
and 31,220 (80%) took part. We excluded women who reported
previous cancer (N = 1367) or who had incomplete data on insom-
nia and/or arm/shoulder pain (N = 7268). Among the rest of 22,585
women we drew at random 5 controls for each BCS based on 5 year
age group, so the age-matched control sample consisted of 1685
women.
2.2. Questionnaire variables
2.2.1. Insomnia (BCSs and controls)
The questionnaires included two questions regarding sleep: (1)
‘‘Have you had problems getting to sleep during the past month?’’
(2) ‘‘During the past month, have you ever woken up too early and
not been able to go back to sleep?’’ There were four alternative re-
sponse categories: ‘‘never’’, ‘‘occasionally’’, ‘‘often’’ and ‘‘almost
every night’’, which were dichotomized into ‘‘present’’ (often/al-
most every night) or ‘‘absent’’ (never/occasionally). Insomnia was
defined as a score of present on one or both questions as used in
previous HUNT-2 studies [16–19].
2.2.2. Arm/shoulder pain, lymphedema, and restricted mobility in BCSs
and controls
Among BCSs we used three items from the EORTC QLQ-BR23
(BR23) breast cancer-specific module of self-rated QoL [20]. During
the past week (1) ‘‘Did you have pain in your arm or shoulder?’’ (2)
‘‘Did you have a swollen arm or hand?’’ and (3) ‘‘Was it difficult to
raise your arm or to move it sideways?’’ The items were rated on a
four-point Likert scale with the categories ‘‘not at all’’, ‘‘a little’’,
‘‘quite a bit’’ and ‘‘very much’’, which were dichotomized into pres-
ent (‘‘quite a bit’’/’’very much’’) or absent (‘‘not at all’’/’’a little’’).
The correlation coefficients (rho) for the raw scores were pain ver-
sus lymphedema 0.50, pain versus restricted mobility 0.61, and
lymphedema versus restricted mobility 0.44. These coefficients
indicated a maximum of 37.2% explained variance between these
585
ASP components, and we concluded that they could be treated as
non-overlapping variables.
From the EORTC QLQ-BR23 (BR23) we also used the bothersome
hot flashes items in addition to the arm/shoulder ones, operational-
ized as present if scored ‘‘quite a bit’’ or ‘‘very much’’ [20].
Among controls the question ‘‘Did you have pain in your shoul-
der during the past month?’’ and correspondingly for elbow pain
was scored as ‘‘yes’’ or ‘‘no’’. Arm/shoulder pain was present if
either response was affirmative.
2.2.3. Fatigue
In the cross-sectional and longitudinal samples of BCSs we used
the Fatigue Questionnaire (FQ) [21] which consists of 13 items rat-
ing physical and mental fatigue. Higher FQ scores imply more fati-
gue. In this study we only included total fatigue (the sum score of
mental and physical fatigue), and the internal consistency for the
total fatigue items was alpha = 0.92.
Feeling fatigued or weak among BCSs was defined by the two
Short Form-36 items of ‘‘feeling tired’’ or ‘‘feeling fatigued’’ for
the past 4 weeks, and a score of ‘‘part of the time’’ or more fre-
quently was considered as ‘‘fatigued or weak’’ [22]. The controls
scored the item ‘‘Did you feel strong and fit or tired and fatigued?’’
the past week. The individuals scoring ‘‘considerably tired and fa-
tigued’’ or worse were considered as ‘‘fatigued or weak’’.
2.2.4. Anxiety and depression
Both the cross-sectional and longitudinal studies used The Hos-
pital Anxiety and Depression Scale (HADS). The HADS consists of 14
items; 7 symptoms of anxiety (HADS-A) and 7 of depression
(HADS-D) [23]. The internal consistency was alpha = 0.88 for
HADS-A and 0.83 for HADS-D.
2.2.5. QoL
For BCSs The Short Form36 (SF-36) was used as generic QoL
instrument which consisted of 36 items and assesses eight dimen-
sions of physical and mental QoL [22]. The dimensional scores
were summarized into the Physical and Mental Component Sum-
mary Scales (PCS and MCS) which were T-transformed so that
the Norwegian general populations mean scores are 50 [24].
2.2.6. Cancer-related variables (2004)
Information on age at diagnosis, type of surgery, radiotherapy
and systemic treatment was retrieved from the BCSs’ medical re-
cords. Treatment was based on the guidelines of the Norwegian
Breast Cancer Group at that time (http://www.nbcg.no/index.html)
and has been described in detail previously [15]. In the 2004 sam-
ple, 76% (N = 256) of the women had been treated with modified
radical mastectomy and 24% (N = 81) with breast-conserving sur-
gery. All women had axillary lymph node dissection at level I–II.
The target volume of post-operative radiotherapy (50 Gy) included
the breast for BC and the chest wall after mastectomy, and all pa-
tients had radiotherapy to the regional lymph node stations includ-
ing the axilla. Adjuvant chemotherapy and/or tamoxifen were
administered according to national guidelines at that time. Two
hundred and seventy-four BCSs (81%) had tamoxifen, 277 (82%)
had chemotherapy, and 230 (68%) used a combination.
2.2.7. Other variables in BCSs and controls
Relationship status was dichotomized as paired (married and
cohabiting) versus non-paired (separated, divorced and widows).
Level of education was categorized as 12 years or >12 years of ba-
sic education. In paid work concerned those working full or part
time versus those not in paid work. On disability pension were indi-
viduals aged <67 years who had <50% work capacity due to dis-
eases or injuries. Self-rated health was based on one item scored
on a four point Likert-scale ranging from ‘‘very good’’ to ‘‘poor’’,
586 A.A. Dahl et al. / Sleep Medicine 12 (2011) 584–590

dichotomized into good (excellent/good) and poor (moderate/ Table 1

poor). Regular use of analgesics, hypnotics, anxiolytics and antidepres- Characteristics of breast cancer survivors with and without insomnia in the cross-
sectional (2004) sample (N = 337).
sants last 12 months was scored as ‘‘yes’’ or ‘‘no’’. The level of phys-
ical activity was categorized into ‘‘minimal’’ versus ‘‘moderate or Variables Insomnia Non-insomnia p ESa
more’’ according to published algorithms [25]. N = 101 N = 236
N (%) N (%)
Arm/shoulder variables
2.3. Statistical analysis Pain 52 (52) 71 (30) <0.001 0.45
Lymphedema 32 (32) 39 (17) 0.002 0.35
Continuous variables were analyzed with t-tests and categorical Restricted mobility 24 (24) 25 (11) 0.002 0.34
variables by chi-square tests. In case of skewed distributions non- Socio-demographic variables
parametric tests were applied. Statistically significant group differ- Age at survey, mean (SD) 55.9 (8.0) 54.3 (8.7) 0.11
ences were examined for clinical significance with effect sizes Level of education 0.17
12 years 71 (70) 146 (62)
(ESs). For continuous variables we used Cohen’s coefficient d >12 years 30 (30) 88 (38)
[26], and for 2  2 contingency tables the differences between arc- Type of relationship 0.48
sine transformed proportions [27,28]. ESs  0.40 were considered Married/cohabiting 76 (75) 185 (79)
clinically significant based on the recommendations of Cohen [26]. Single/divorced/widow 25 (25) 50 (21)
In paid work 49 (48) 148 (63) 0.02
Internal consistencies of scales were given by Cronbach’s coeffi-
On disability person 44 (44) 64 (27) 0.003 0.34
cient alpha, correlations with Spearman’s coefficient rho, and con-
Cancer-related variables
cordance between groups with Cohen’s coefficient kappa. Bivariate
Time since surgery, mean (SD) 4.0 (0.8) 4.0 (0.9) 0.90
logistic regression analyses were used to explore the associations Type of surgery 0.53
between various independent variables and insomnia as depen- Radical modified mastectomy 79 (78) 177 (75)
dent variables both in the cross-sectional and the longitudinal Lumpectomy 22 (22) 59 (25)
sub-studies. The strength of the associations was expressed as Had chemotherapy 79 (78) 198 (84) 0.21
Had hormone therapy 80 (79) 194 (82) 0.52
odds ratios (OR) with 95% confidence intervals (95%CI). The inde-
pendent variables did not show multi-collinearity when exposed Somatic health variables
Self-rated health <0.001 0.45
to the variance inflation test, except for anxiety, depression and Poor/not so good 43 (43) 52 (22)
MCS, and therefore only anxiety was included in the multivariate Good/excellent 58 (57) 182 (78)
analyses. The independent variables showing a significant associa- SF-36 PCS, mean (SD)b 40.0 (10.7) 46.1 (10.0) <0.001 0.60
tion with the dependent variable were included in the multivariate Postmenopausal status 94 (93) 208 (88) 0.17
Bothersome hot flashes 66 (66) 100 (44) <0.001 0.45
analyses which were done in a non-hierarchical way.
Regular use of analgesics 32 (32) 24 (10) <0.001 0.56
The analyses were done on PASW for Windows, version 17.0. Total fatigue, mean 17.2 (5.8) 14.1 (5.5) <0.001 0.55
Due to multiple comparisons the level of significance was set at
Mental health variables
p < 0.01, and all tests were two-sided. HADS-depression, mean (SD)b 4.0 (3.6) 2.7 (3.0) <0.001 0.41
HADS-anxiety, mean (SD)b 7.4 (3.0) 5.8 (2.6) <0.001 0.59
Regular use of hypnotics 36 (36) 13 (6) <0.001 0.79
2.4. Ethical considerations
Regular use of anxiolytics 11 (11) 13 (6) 0.08
Regular use of antidepressants 15 (15) 19 (8) 0.06
Both the BCSs study and HUNT-2 were approved by the Regio- SF-36 MCS, mean (SD)b 48.9 (11.1) 52.7 (8.6) 0.002 0.40
nal Ethical Committees of Norway and by the National Data Inspec- a
Effect size.
torate. All patients and controls gave written informed consent. b
Non-parametric tests.

3. Results
3.1. Findings on insomnia in BCSs (cross-sectional 2004 sample)
Median age of BCSs at survey was 55.3 years (range 29–
75 years), and the time since diagnosis was median 3.9 years
(range 2.6–6.9 years) in 2004. Of 337 BCSs, 101 (30%, 95%CI 25–
35%) reported insomnia. Concerning ASPs, 37% (95CI 31–42%) re-
ported arm/shoulder pain, 21% (95%CI 17–25%) swelling, and 15%
(95%CI 11–18%) restricted mobility. All these ASPs were signifi-
cantly more common in BCSs with insomnia versus those without
insomnia, but the differences were clinically significant only for
arm/shoulder pain (ES = 0.45) (Table 1).
BCSs with insomnia more often received disability pension and
had poor self-rated health, more bothersome hot flashes, higher le-
vel of fatigue and poorer level of physical and mental QoL than
BCSs without insomnia (Table 1). Further, the levels of anxiety
and depression and the proportions of regular users of analgesics
and hypnotics were significantly higher in BCSs with insomnia.
All these group differences, except the proportion on disability
pension, reached clinical significance. None of the cancer-related
variables were significantly associated with insomnia.
In the bivariate analyses both arm/shoulder pain, lymphedema
and restricted mobility were significantly associated with insom-
nia, showing ORs between 2.34 and 2.63 (Table 2). Increasing levels
of total fatigue (OR = 1.11), anxiety (OR = 1.22) and depression
(OR = 1.13) showed significant associations with insomnia, as did
decreased levels of physical (OR = 0.95) and mental (OR = 0.96)
QoL. Regular use of hypnotics showed the strongest association
with insomnia in bivariate analysis (OR = 9.50) and was the only
significant variable associated with insomnia in the multivariate
analyses (ORs = 7.92–7.94) (Table 2). In the multivariate analyses
neither arm/shoulder pain, lymphedema or restricted mobility
showed significant associations with insomnia.
3.2. The longitudinal sub-study
The median interval between the cross-sectional 2004 and 2007
surveys was 2.5 years (range = 1.6–4.0). Thirty-three percent
(95%CI 27–39%) of BCSs reported insomnia in 2007. Twenty per-
cent reported insomnia both in 2004 and 2007, while 58% never re-
ported insomnia. In 10% insomnia had disappeared during the
longitudinal observation, while in 12% insomnia had emerged.
The kappa statistic for concordance in 2004 and 2007 was 0.47
(moderate agreement) [26].
In bivariate analyses arm/shoulder pain (OR = 3.17) and re-
stricted mobility (OR = 2.83) in 2004 were significant predictors of
insomnia in 2007 (Table 3). Other significant 2004 predictors in
bivariate analyses were being on disability pension (OR = 2.95),
poorer self-rated health (OR = 2.25), regular use of analgesics
 A.A. Dahl et al. / Sleep Medicine 12 (2011) 584–590 587

Table 2
Logistic regression analysis of various independent variables in breast cancer survivors and insomnia symptoms (present or absent) as dependent variable (2004 sample).

Independent variables Univariate analysis Multivariate analysis

OR 95% CI p OR 95% CI p
Arm/shoulder pain 2.46 1.53–3.98 <0.001 1.10 0.59–2.07 0.76
On disability pension 2.08 1.28–3.38 0.003 0.96 0.50–1.82 0.89
Poor self-rated health 2.60 1.57–4.28 <0.001 0.75 0.35–1.57 0.44
SF-36 PCS score 0.95 0.93–0.97 <0.001 0.98 0.94–1.01 0.17
Bothersome hot flashes 2.52 1.55–4.11 <0.001 1.89 1.07–3.35 0.03
Regular use of analgesics 4.10 2.26–7.43 <0.001 1.74 0.79–3.83 0.17
Total fatigue score 1.11 1.06–1.16 <0.001 1.05 0.98–1.11 0.16
Anxiety scorea 1.22 1.12–1.32 <0.001 1.11 0.99–1.24 0.07
Depression score 1.13 1.05–1.21 0.001 – – –
SF-36 MCS score 0.96 0.94–0.98 0.001 – – –
Regular use of hypnotics 9.50 4.76–18.98 <0.001 7.92 3.40–18.43 <0.001
Lymphedema 2.34 1.36–4.03 0.002 1.04 0.51–2.11 0.92
On disability pension 0.97 0.51–1.83 0.92
Poor self-rated health 0.74 0.35–1.56 0.43
SF-36 PCS score 0.97 0.94–1.01 0.14
Bothersome hot flashes 1.92 1.09–3.37 0.02
Regular use of analgesics 1.74 0.78–3.85 0.17
Total fatigue score 1.04 0.98–1.11 0.16
Anxiety scorea 1.11 0.99–1.24 0.07
Regular use of hypnotics 7.92 3.39–18.48 <0.001
Restricted movement 2.63 1.42–4.03 0.002 1.02 0.46–2.30 0.96
On disability pension 0.97 0.51–1.83 0.92
Poor self-rated health 0.74 0.35–1.56 0.43
SF-36 PCS score 0.97 0.94–1.01 0.14
Bothersome hot flashes 1.92 1.09–3.37 0.02
Regular use of analgesics 1.73 0.78–3.82 0.18
Fatigue score 1.05 0.98–1.11 0.16
Anxiety scorea 1.11 0.99–1.24 0.06
Regular use of hypnotics 7.94 3.41–18.49 <0.001
a
Due to high correlation (rho = 0.55) between anxiety, depression, and MCSs only anxiety was entered in the multivariate analysis.

(OR = 3.02) and of hypnotics (OR = 5.63), and increasing total fatigue
score (OR = 1.11). Increased levels of insomnia (OR = 8.79), anxiety
(OR = 1.26), and decreasing mental QoL (OR = 0.94) were also signif-
icant predictors of insomnia in the longitudinal substudy. Decreas-
ing physical QoL (OR = 0.97), bothersome hot flashes (OR = 2.09),
and increasing depression (OR = 1.11), all with p = 0.01 in bivariate
analyses, were close to significant predictors of insomnia in 2007.
In the multivariate analysis only insomnia in 2004 (OR = 5.41) was
a significant predictor of insomnia in 2007 (Table 3).
3.3. Comparison between BCSs (cross-sectional 2004 sample) and
controls
Thirty percent (95%CI 25–35%) of BCSs had insomnia in con-
trast to 18% (95%CI 17–20%) among controls (p = 0.002). Among
BCSs 37% (95%CI 31–42%) had arm/shoulder pain which was also
the case for 26% (95%CI 23–28%) among controls (p = 0.003) (Ta-
ble 4). Forty-two percent of BCSs with arm/shoulder pain re-
ported insomnia, and so did 25% of the controls with such pain
(p < 0.001). Compared to controls, a significantly higher propor-
tion of BCSs had disability pension, higher level of education,
and reported postmenopausal status (Table 4). We report findings
adjusted for these differences in the analyses. A higher proportion
of BCSs used hypnotics regularly, felt fatigued or weak, and had
moderate or more physical activity compared to controls. BCSs
also had a significantly higher level of anxiety, but lower level
of depression compared to controls. The differences concerning
postmenopausal status, feeling fatigued and weak, use of hypnot-
ics, moderate or more physical activity and higher level of anxiety
were clinically significant.

Table 3
Logistic regression analysis of independent variables in breast cancer survivors 2004 and insomnia symptoms in 2007 (present/absent) as dependent variable.

Independent variables in 2004 Univariate analyses Multivariate analyses

OR 95% CI p OR 95% CI p
Arm/shoulder pain 3.17 1.83–5.51 <0.001 2.04 0.95–4.36 0.07
Lymphedema 2.11 1.14–3.88 0.02 – – –
Restricted motion 2.83 1.41–5.68 0.003 – – –
Age at 2004 survey 1.01 0.98–1.04 0.60 – – –
On disability pension 2.95 1.69–5.15 <0.001 2.27 1.07–4.81 0.03
Poorer self-rated health 2.25 1.29–3.95 <0.001 0.81 0.33–1.96 0.52
SF-36 PCS score 0.97 0.95–0.99 0.01 1.04 0.99–1.08 0.10
Bothersome hot flashes 2.09 1.21–3.61 0.01 1.25 0.63–2.46 0.52
Regular use of analgesics 3.02 1.53–5.95 0.001 1.22 0.47–3.21 0.68
Total fatigue score 1.11 1.06–1.17 <0.001 1.06 0.98–1.14 0.13
Anxiety score 1.26 1.14–1.39 <0.001 1.12 0.98–1.28 0.11
Depression scorea 1.11 1.02–1.20 0.01 – – –
SF-36 MCS score 0.94 0.91–0.97 <0.001 – –
Regular use of hypnotics 5.63 2.65–11.95 <0.001 2.26 0.81–6.36 0.12
Insomnia symptoms 8.79 4.74–16.30 <0.001 5.41 2.62–11.15 <0.001
a
Due to high correlation (rho = 0.55) between anxiety, depression, and MCSs only anxiety was entered in the multivariate analysis.
588 A.A. Dahl et al. / Sleep Medicine 12 (2011) 584–590

Table 4 4. Discussion
Characteristics of breast cancer survivors (cross-sectional 2004 sample) and controls.

Variables BCSs Controls p ESa In this controlled cross-sectional and longitudinal study of arm/
N = 337 N = 1685 shoulder problems and insomnia in BCSs our main findings were
Age at survey, mean (SD) 54.8 (8.5) 54.2 (8.7) 0.28 (1) arm/shoulder pain, lymphedema and restricted mobility were
N (%) N (%) all significantly associated with insomnia studied cross-sectionally.
Insomnia symptoms 101 (30) 310 (18) 0.002c 0.26
Such associations were also observed for being on disability pen-
Arm/shoulder pain 123 (37) 429 (26) 0.003c 0.24
Level of education <0.001 0.36 sion, poor self-rated health, reduced physical and mental QoL,
12 years 217 (65) 1318 (81) bothersome hot flashes, increasing levels of fatigue, anxiety and
>12 years 118 (35) 318 (19) depression as well as regular use of hypnotics and analgesics. Only
Paired relationship 0.26 regular use of hypnotics was significantly associated with insom-
Married/cohabiting 261 (78) 1354 (80)
nia in cross-sectional multivariate analysis. (2) In bivariate analy-
Single/divorced/widow 75 (22)
In paid work 197 (59) 1135 (67) 0.002 0.17 ses arm/shoulder pain and restricted mobility were significant
On disability pension 108 (32) 262 (16) <0.001 0.38 predictors of insomnia 3 years later. Other significant predictors
Self-rated health <0.001c 0.15 were being on disability pension, poorer self-rated health, increas-
Poor/not so good 95 (28) 579 (35)
ing levels of fatigue, anxiety and depression, reduced mental QoL,
Good/excellent 240 (72) 1092 (65)
Postmenopausal status 302 (90) 1106 (65) <0.001 0.64
as well as regular use of hypnotics and analgesics. However, the
Regular use of analgesics 56 (17) 244 (5) 0.73c only significant predictor of insomnia in multivariate analysis
Feeling fatigued or weak 139 (41) 267 (16) <0.001c 0.57 was insomnia present 3 years previously. (3) BCSs showed signifi-
Obesity (BMI  30) 53 (18) 328 (19) 0.24c cantly higher prevalence of insomnia and regular use of hypnotics
Anxiety, mean (SD)b 6.3 (2.8) 4.8 (3.7) <0.001c 0.42
compared to age-matched controls from the general population.
Depression, mean (SD)b 3.1 (3.3) 3.7 (3.1) <0.001c 0.19
Regular use of hypnoticsc 49 (15) 70 (4) <0.001c 0.40 BCSs also had a significantly higher prevalence of arm/shoulder
Physical activity <0.001c 0.45 pain. (4) In bivariate analyses the following variables were com-
Minimal 33 (10) 446 (27) monly associated with insomnia in BCSs and controls: arm/shoul-
Moderate or more 300 (90) 1239 (73)
der pain, being on disability pain, poor self-rated health, increased
a
Effect size. level of fatigue, anxiety and depression, as well as regular use of
b
Non-parametric tests. analgesics and hypnotics. However, age at survey, lower level of
c
Adjusted for level of education, on disability pension and menopausal status. education, non-paired relationship and not being in paid work
were significantly associated with insomnia among controls only.
3.4. Variables associated with insomnia in BCSs and controls In multivariate analysis only regular use of hypnotics was signifi-
cantly associated with insomnia among BCSs, while regular use
In bivariate analyses BCSs and controls had the following inde- of analgesics and increasing anxiety score also were significantly
pendent variables that were significantly associated with insomnia associated with insomnia among controls.
in common: arm/shoulder pain, being on disability pension, poor Our findings were in line with earlier findings in BCSs concern-
self-rated health, regular use of analgesics, fatigue, increasing anx- ing factors associated with insomnia such as reduced QoL [9],
iety and depression scores, and regular use of hypnotics. In addi- poorer physical health, bothersome hot flashes, increased levels
tion, low level of education, non-paired civil status, and not of fatigue, anxiety and depression [10,19], being on disability pen-
being in paid work were significantly associated with insomnia sion [17] and increased use of analgesic and hypnotics [18]. This
in the bivariate analyses of the controls (Table 5).While only regu- correspondence supported the validity of our findings.
lar use of hypnotics was significantly in the multivariate analysis In contrast to other studies, we did not find any significant asso-
among BCSs, regular use of analgesics and increasing level of anx- ciation with cancer-related variables in our BCSs sample. This find-
iety were significantly associated with insomnia in such analysis ing could be due to lack of variation because of the homogenous
among the controls (Table 5). treatment given to our BCSs.

Table 5
Logistic regression analyses of independent variables associated with insomnia symptoms as dependent variable (non-insomnia as reference) in the samples of BCSs (N = 337) and
controls (N = 1685).

Variables Breast cancer survivors (N = 337) Controls (N = 1685)

Bivariate analyses Multivariate analyses Bivariate analyses Multivariate analyses
OR 95% CI p OR 95% CI p OR 95% CI p OR 95% CI p
Age at survey 1.1 1.0–1.1 0.11 – – – 1.1 1.0–1.4 <0.001 1.0 0.9–1.0 0.16
Arm/shoulder pain 2.5 1.5–4.0 <0.001 1.5 0.9–2.7 0.16 1.7 1.3–2.2 <0.001 1.1 0.8–1.4 0.76
Low level of education (>12 years = reference) 1.4 0.9–2.4 0.17 – – – 1.6 1.1–2.2 0.001 1.2 0–8–1.8 0.43
Single/divorced/widow (married/cohabiting = ref) 1.2 0.7–2.1 0.48 – – – 1.5 1.1–2.0 0.007 1.5 1.1–2.1 0.02
In paid work 0.6 0.4–0.9 0.02 – – – 0.5 0.4–0.7 <0.001 0.9 0.7–1.3 0.67
On disability pension 2.3 1.3–3.4 0.003 1.1 0.6–2.0 0.77 2.9 2.2–3.9 <0.001 1.4 0.9–2.0 0.10
Poor/not so good self-rated health (good/excellent = ref) 2.6 1.6–4.3 <0.001 1.0 0.5–2.0 0.95 3.2 2.5–4.1 <0.001 1.3 1.0–1.9 0.091
Postmenopausal status 1.8 0.8–4.3 0.18 – – – 1.7 1.3–2.2 <0.001 1.2 0.8–1.8 0.44
Regular use of analgesics 4.1 2.3–7.4 <0.001 1.8 1.0–3.2 0.12 3.3 2.5–4.5 <0.001 2.2 1.6–3.2 <0.001
Feeling fatigued or weak 2.7 1.7–4.4 <0.001 1.8 1.0–2.9 0.06 3.1 2.3–4.2 <0.001 1.3 0.9–1.9 0.16
Obesity (BMI  30) 1.7 0.9–3.1 0.11 – 0.8 0.6–1.1 0.24 – –
HADS-anxiety score 1.2 1.1–1.3 <0.001 1.1 1.0–1.2 0.04 1.2 1.1–1.3 <0.001 1.2 1.1–1.3 <0.001
HAd-depression scorea 1.1 1.1–1.2 0.001 – – – 1.2 1.1–1.3 <0.001 – – –
Regular use of hypnotics 9.5 4.8–19.0 <0.001 7.0 3.9–15.3 <0.001 10.5 6.3–17.6 <0.001 4.9 2.7–9.0 <0.001
Minimal physical activity (moderate or more = ref) 2.6 1.0–6.9 0.06 – – – 0.8 0.6–1.0 0.09 – – –
a
Due to high correlation (rho = 0.55) between anxiety, depression, only anxiety was entered in the multivariate analysis.
 A.A. Dahl et al. / Sleep Medicine 12 (2011) 584–590
In the comparison of BCSs and controls, we observed that
increasing age, non-paired relation status, not being in paid work,
and postmenopausal status were significantly associated with
insomnia among controls in accordance with previous findings in
the general population [11,12].
We also documented a considerable stability of insomnia over a
close to 3 year observation period among BCSs, which is in accor-
dance with findings in the general population [29].
New findings concern the three components of arm/shoulder
problems typical for BCSs who had surgery and radiation to the ax-
illa, in relation to insomnia. In our study arm/shoulder pain,
lymphedema and restricted mobility were all associated with
insomnia, but arm/shoulder pain most strongly so. Optimal pre-
vention and treatment of arm/shoulder problems in BCSs could
be relevant for prevention of insomnia. Thirty-two percent of BCSs
with insomnia used analgesics regularly, and among BCSs with
arm/shoulder pain analgesics were used regularly by 25%. Interest-
ingly, the proportion using analgesics regularly among controls
with such pain was similar (25%). These findings raise doubts con-
cerning adequate analgesia among BCSs, which is one way to im-
prove insomnia in these patients.
In the longitudinal sub-study the strongest predictor of current
insomnia among BCSs was previous insomnia. In this regard regu-
lar use of hypnotics by 36% of BCSs with insomnia is of interest.
These findings raise the issue of both under-treatment and over-
treatment of insomnia in BCSs. We assume that only a small pro-
portion of BCSs with insomnia have been offered non-pharmaco-
logical treatment since a study documented that such treatment
rarely is offered in Norway [30]. The lack of non-pharmacological
treatment alternatives for insomnia is regrettable since their supe-
riority over pharmacotherapy has been well documented [31].
Report of insomnia while simultaneously using hypnotics indi-
cates lack of effect or that use of hypnotics, such as short-acting
ones, may cause insomnia through withdrawal effects. Studies
have shown that Norwegian general practitioners prescribed ben-
zodiazepines or Z-drugs (zopliclone, zolpidem and zaleplon) for
>6 months to one-third of their insomnia patients, although these
drugs are recommended only for short-term use [18,30]. The con-
sequences of under-treatment of insomnia in general are consider-
able, with impaired daytime cognitive functioning and increased
risk of automobile accidents and falls [32] and eventually increased
overall mortality and risk of suicide [33]. Unfortunately, the prob-
lems of long-term use of hypnotics and eventual over-treatment in
cancer patients with chronic insomnia are hardly discussed in the
oncological literature [9,34]. A clinical conclusion from our study is
that insomnia in the individual BCSs should be actively investi-
gated, and the effects of hypnotics and analgesics should be regu-
larly monitored and adapted since both over and under-treatment
can have serious consequences.
Our study should be considered in light of some strengths and
limitations. Among the strengths are a considerable sample size
of BCSs and the combination of cross-sectional and longitudinal
observations as well as a high number of controls from the general
population. Both the definition of insomnia and several relevant
Norwegian studies of insomnia put our findings into context.
Among limitations is the lack of information on distress or
impairment as a consequence of insomnia as well as more specific
information on medication for insomnia. Another limitation con-
cerns the use of self-reported data without validation from struc-
tured interviews, which can lead to bias, particularly since
insomnia may lead to impaired memory and recall. Another limita-
tion which must be considered is that definitions of some variables
like fatigue did not completely correspond between BCSs and con-
trols. However, the main limitation is our problem with teasing out
the effects of arm/shoulder problems in relation to other signifi-
cant factors in both cross-sectional and longitudinal designs such
589
as fatigue, anxiety, depression and the use of hypnotics, which all
are reported to be independent variables related to insomnia in
general.
In conclusion, we have added new knowledge concerning the
relevance of arm/shoulder pain, lymphedema and restricted move-
ment for insomnia in BCSs. The strong predictive effect of previous
insomnia in BCSs for later insomnia points to the need of regular
monitoring of sleep problems in these patients. Our finding—BCSs
with arm/shoulder pain had more insomnia than general popula-
tion controls with such pain—supported this conclusion.
Conflict of Interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of
Interest associated with this article can be viewed by clicking on
the following link: doi: doi:10.1016/j.sleep.2011.01.011.
Acknowledgments
Inger-Lise Nesvold, RPT, MHSci holds a PhD grant sponsored by
The Norwegian Research Council and the Legacies of the Norwe-
gian Radium Hospital and National Resource Centre for Women’s
Health, Oslo University Hospital, Rikshospitalet.
The Nord-Trøndelag Health Study (The HUNT Study) is a collab-
oration among HUNT Research Centre, Faculty of Medicine, Norwe-
gian University of Science and Technology (NTNU, Verdal),
Norwegian Institute of Public Health, and Nord-Trøndelag County
Council.
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