Quality of Sleep and Related Factors in Patients with Esophageal Cancer

Research Article

Austin J Public Health Epidemiol. 2015; 2(3): 1025.

Quality of Sleep and Related Factors in Patients with Esophageal Cancer

Szu-Hsiu Liu¹, Yen-Hao Chen², Chao-Hsien Lee³, Wen-Li Hou¹, Pi-Li Lin¹, Chun-Chieh Chao4 and Tsan Yang³*

¹Department of Nuring, Meiho University, Pingtung County, Taiwan

²Department of Hematology-Oncology, Kaohsiung Chang Gung University College of Medicine, Taiwan

³Department of Health Business Administration, Meiho University, Pingtung County, Taiwan

4Department of Senior Citizen Service Management, Yuh-Ing Junior College of Health Care and Management, Taiwan

*Corresponding author: Tsan Yang, Department of Health Business Administration, Meiho University, Ping Kuang Road, Neipu, Pingtung, 91202, Taiwan

Received: August 17, 2015; Accepted: October 06, 2015; Published: October 10, 2015


Background: Insomnia is one of the most common problems faced by cancer patients, with approximately 50% of patients experiencing it. Esophageal cancer is the most aggressive and deadly cancer of the digestive system. Patients with esophageal cancer often experience physical side effects that influence the balance between their physiological, psychological, and social states.

Aim: The purpose of the study was to investigate what related factors affect the quality of sleep in patients with esophageal cancer.

Methods: This was a cross-sectional study design. This approach involved using the Chinese Pittsburgh Sleep Quality Inventory (CPSQI), the background information of patients with esophageal cancer and their associated medicinerelated variance data. From March 2, 2015 to April 30, 2015, a deliberate sampling was collected at a medical center in Kaohsiung, Taiwan, where patients with esophageal cancer were targeted and recruited from an oncology ward, oncology clinics, a joint clinic of cardiothoracic and vascular surgery and esophageal cancer.

Results: A total of 100 patients with esophageal cancer participated. Statistical analyses were carried out using SPSS 18.0. The results showed an average score of 8.03 on the CPSQI, with 65 participants (65.0%) reporting poor quality of sleep. The quality of sleep was also found to be correlated with daily tobacco consumption, the ability to look after one self, and being underweight. According to the multiple linear regression results, the amount of tobacco consumed, self-awareness level, ability to look after oneself, Body Mass Index (BMI), and total score on the Chinese version of the Epworth Sleepiness Scale (CESS) were the most important predictors of the CPSQI quality of sleep.

Conclusion: Patients with esophageal cancer encounter quality of sleep problems of varying severity as the disease progresses. Clinical care workers should actively absorb professional knowledge, focus on patients’ health conditions, and provide patients with complete nursing care education and procedures. By doing so, problems relating to quality of sleep in patients with esophageal cancer can be solved, and the overall quality of nursing care can be improved.

Keywords: Cancer patients; Esophageal cancer; Quality of sleep; CPSQI


CPSQI: Chinese Pittsburgh Sleep Quality Inventory; CESS: Chinese version of the Epworth Sleepiness Scale; BMI: Body Mass Index


According to research, in Taiwan esophageal cancer was ranked 10th in death rates, but the ranking rose to the 9th in 2013; moreover, esophageal cancer was ranked in the top five of the male’s deadly cancer [1]. Which Middle-aged males are more likely to be affected by esophageal cancer, and most esophageal cancer patients smoked, drank alcohol, or chewed betel nuts in their youth. Because there are no significant symptoms in the early stages of esophageal cancer, most patients who are admitted to hospital to treat dysphagia or extreme pain have already been in stage 3 of cancer, including metastasis or terminal symptoms, and thus receive a diagnosis of esophageal squamous cell carcinoma with a poor prognosis [2,3]. The survival rate for esophageal cancer is less than 50% in the first year after diagnosis [4]. Moreover, esophageal cancer is one of the most malignant cancers in the gastrointestinal tract [4,5]. Over the past several years, a form of preoperative concurrent chemo radiotherapy (trimodality therapy) has been adopted gradually in clinical practice [3,4]. However, after the therapy, patients often suffer from physical side effects influencing their physical, psychological, and social states. Cancer patients experience fears of disability, role loss, body disfigurement, reliance, loss of control, loss of autonomy, and loss of daily life (For example, eating habits, personal hygiene, using the toilet, showering, take on and off the clothes, the control of defecate and urine, walking on flat ground, walking up and down the stairs, getting on and off the bed and sit on and stand up from chair) [6]. In physical terms, esophageal cancer patients often suffer from dysphagia, malnutrition, pain and exhaustion, while in terms of social and psychological problems, these patients suffer from the psychological stress, hopelessness, and uncertainty caused by the cancer [4].

Insomnia is one of the most common sleep disorders affecting cancer patients. Approximately 50% of cancer patients have experienced insomnia, and roughly 48% of cancer patients state that they have suffered from insomnia in the six months before and the eighteen months after their cancer diagnosis [7]. Insomnia influences the patients’ emotions, cognitive functions, social functions, and quality of life [8]. Furthermore, even though oncology experts have long noticed changes in patients’ sleep patterns, sleep problems were rarely evaluated until some studies investigating sleep disorders among cancer patients were conducted in recent years [8-11].

However, in Taiwan, the past studies investigating sleep disorders have focused on breast cancer patients and lung cancer patients; there have been no studies focusing on sleep disorders among esophageal cancer patients. Thus, this study sought to investigate the factors influencing sleep quality among esophageal cancer patients and is intended to serve as a reference for providing better quality care to esophageal cancer patients in the future.


Study design

This study employed a cross-sectional study design. A purposive sampling method was adopted to collect the data from the hematology– oncology ward and clinic, the thoracic and cardiovascular surgery ward and clinic, the joint clinic for esophageal cancer, and the radiation oncology clinic of a medical center in Kaohsiung, a city in southern Taiwan. This study was approved by the Institutional Review Board of the hospital and the data was collected via structured questionnaires.

Inclusion criteria

1. Patients who were clinically diagnosed with esophageal cancer (ICD-10).

2. Patients who underwent surgery, chemotherapy, or radiotherapy after diagnosis with esophageal cancer.

3. Patients who were conscious and able to express their thoughts clearly.

4. Patients aged 20 years old or older.

5. Patients who were able to communicate in Chinese or Taiwanese.

Exclusion criteria

1. Patients who were not able to understand the purpose of this study.

2. Patients who were not able to fill out the questionnaire because of severe illness.

This study was conducted from March 2, 2015 to April 30, 2015. On account of time constraints on the hospital’s activities, among 121 cases that were considered to meet the qualification of the experiment, 100 patients gave their consent and turned out to participate in the research. As a result, 100 valid questionnaires were collected. Three main reasons why some patients refused to participate in the research are physical un-comfortableness due to illness, uncomfortable feelings of being studied, and insufficient time to do questionnaires because patients rushed to the next treatment.

Data collection

This study employed structured questionnaires, and the study data and tools included the following: (1) basic patient information (e.g., age, gender, ethnicity, level of education, marital status, religion, occupation, retirement status, income, alcohol intake, betel nut chewing, private medical insurance, living situation, self-care ability, and care provided by family and friends), which was filled in or otherwise provided by the patients themselves. If patients were illiterate, the researcher would recite all the questions regarding basic information in Chinese and Taiwanese for them to reply. (2) A medical variance form, including information on the time of esophageal cancer diagnosis, source (clinic/ward), Body Mass Index (BMI) (Kg/ m²), past health status (medical history/cancer history), diagnosis information (type/stage), treatment status (medical treatment/ the number of treatments), and side effects (physical conditions caused by the cancer/ treatment side effects), was collected from the medical records by the researchers. (3) The Chinese Pittsburgh Sleep Quality Inventory (CPSQI), which consisted of nineteen questions covering seven dimensions, namely, subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, daytime dysfunction, and use of sleep medication. Each question was scored from 0-3, with a total score of 21 points. Higher scores indicated poorer sleep quality. In terms of total scores, the cut-point was set at the 5-point mark, where a total score = 5 indicated good sleep quality and a total score > 5 indicated poor sleep quality. Tsai et al., (2005) stated that the CPSQI has a good internal consistency and reliability (Cronbach’s a= 0.82 - 0.83), with retest reliabilities of 0.85 (for all participants) and 0.77 (for participants with primary insomnia) [12] at 14-20 days after an initial administration of the test. The CPSQI is a good research tool with stability and sensitivity. (4) The Chinese version of the Epworth Sleepiness Scale (CESS) is a Chinese translation of the Epworth Sleep Scale (ESS), which was translated by Chen et al., in 2002 to evaluate participants’ daytime sleepiness. The CESS consists of eight self-evaluated situations, including sitting and reading, watching television, sitting inactively in a public place (e.g., a cinema or a meeting), being in a car for an hour as a passenger (without a break), lying down to rest in the afternoon, sitting and chatting with someone, sitting quietly after lunch (not having had alcohol), and sitting in a stopped car in traffic for a few minutes. Scoring used a Likert scale (0-3 points) for total scores of between 0 and 24. The higher the score, the higher the possibility of sleepiness was. A total score ? 10 indicated a daytime sleepiness problem [13]. Full consent to use CPSQI and CESS was granted.

Statistical analysis

SPSS 18.0 was adopted for statistical analysis. Descriptive statistics included the following: number, percentages. Inferential statistics included the following: the Chi-squared test was used for the difference between the variables and sleep quality; while linear multiple regression analysis was used to investigate the factors influencing the sleep quality of esophageal cancer patients.


One hundred patients participated. The average age of the participants was 54.72 ± 8.75 years. Most of them were between 50 and 60 years old (45 participants, 45.0%), and the participants over the age of 60 constituted the smallest proportion (26.0%). All the participants were male and had esophageal cancer. (Table 1) shows that there were 65 participants with poor sleep quality. In terms of the differences between demographic data and sleep quality, the results showed that the patients who smoked = 40 cigarettes a day had poorer sleep quality than those who smoked > 40 cigarettes a day (96.9% vs. 3.1%), with a statistically significant difference (p=0.013); the patients who felt physical discomfort and needed total assistance from others had the poorest sleepy quality (100.0% vs. 90.0% vs. 83.3% vs. 45.5%; p < 0.001); other variables showed no significant difference with sleep quality (Table 2). (Table 3) shows the relationship between medical variables and sleep quality. The patients who were underweight (BMI<18.5kg/m²) had the poorest sleep quality (84.0% vs. 69.8% vs. 45.8% vs. 37.5%), with a statistically significant difference (p =0.012); other variables showed no significant difference with sleep quality. In terms of the investigation of the predictive factors that influence sleep quality of patients with esophageal cancer, CPSQI is dependent variables. The relation of dependent variables, univariant analysis, basic patient information, and medical variables was taken into consideration. Based on Chi-square tests and Pearson’s productmoment correlation coefficient, the results showed statistically significant level (p<0.200) that was adopted as independent variables in linear regression model. (Table 4) shows that a Variance Inflantion Factor (VIF) is 1.013-1.094 (<10), and tolerance is 0.914-0.987 (>0.1). As a result, Independent variable shows no collinear problem.