3 QUESTIONS ON . . . A Tai Chi Intervention for Insomnia in Breast Cancer Survivors

Michael Irwin, MD: Michael Irwin, MDChronic insomnia is prevalent in breast cancer survivors and as many as 30 percent of breast cancer survivors have symptoms that meet the criteria for this sleep disorder (i.e., twice the rate among the general population). Significantly, chronic insomnia is linked to types of inflammation that increase risk for a host of chronic conditions and health issues, including heart disease, diabetes, stroke, Alzheimer's disease, and cancer recurrence, which makes addressing these sleep issues in cancer patients important, noted Michael Irwin, MD, Professor in the Department of Psychiatry and Biobehavioral Sciences at UCLA Health. Irwin is the lead study author on a paper that examined the benefits of a tai chi intervention versus cognitive behavioral therapy for insomnia (CBT-I) for breast cancer survivors (BBI 2024; https://doi.org/10.1016/j.bbi.2024.05.022). CBT-I is the gold-standard, first-line therapy recommended for people with insomnia. This recent study showed that patients practicing tai chi had a more significant, sustained reduction in certain biomarkers of inflammation compared to patients undergoing CBT-I. “What is important for cancer survivors to know is that they have the agency to improve their own health if they struggle with sleep with one of these interventions,” Irwin noted. “These treatments can profoundly improve sleep health, which will decrease risk of infection and decrease inflammatory processes linked to cancer recurrence, cardiovascular disease, diabetes, dementia, and more.” Irwin shared more about the research and its implications. 1 Why investigate tai chi as an alternative treatment to CBT-I for breast cancer patients with insomnia? “There are limited practitioners who can administer CBT-I. This means there are many patients with insomnia who go untreated or use medications to treat insomnia (which have limited efficacy over time and side effects). We wanted to design a study that evaluated another intervention that is readily available. Tai chi is a community-based, low-cost intervention that can be delivered to patients who are survivors of cancer. “A previous study from our group showed that, in a general population of older adults without a history of cancer, tai chi was non-inferior for the treatment of insomnia compared with CBT-I for up to 7 months (Biol Psychiatry 2015; doi: 10.1016/j.biopsych.2015.01.010). However, in the 1-year follow-up analysis, those in the tai chi group had recurrence of insomnia. But the data also showed that the older adults in the tai chi group were not consistently practicing tai chi after the initial 16 weeks of the study. “For this more recent research that followed a group of 90 breast cancer survivors (all years out from diagnosis and treatment of their cancer), those in the tai chi group continued to practice it (10-15 minutes per day) and the intervention continued to be non-inferior for up to 15 months of follow-up. We know from focus groups conducted before the study started that, among these breast cancer survivors, there was significant concern their insomnia not only contributed to poor health during the day—including poorer mental health and concentration problems—but that it actually could increase the risk of long-term cancer recurrence. “So, they were very motivated to manage their insomnia. And this may help explain why they were more likely than the general population we looked at to continue the tai chi practice.” 2 Explain inflammatory biomarkers and their significance? “The findings that tai chi was non-inferior to CBT-I in breast cancer survivors for the treatment of insomnia were published in the Journal of Clinical Oncology (2017; https://doi.org/10.1200/JCO.2016.71.028). The data for this paper in Brain, Behavior, and Immunity focused on the extent the inflammation we know occurs in people with insomnia could be reversed. “We found that even though tai chi and CBT-I had similar rates of insomnia remission, the tai chi intervention showed a greater benefit in reducing cellular inflammation compared to CBT-I. That finding is similar to what we had also seen in the previous research in a general population of older adults—that tai chi was linked to a greater reduction in cellular markers of inflammation even though those individuals did not necessarily see a sustained reduction in insomnia symptoms. “I want to emphasize that both groups did show a decrease in the transcriptional regulation of inflammation, which is another biomarker of inflammation linked to disturbed sleep. But then, those changes can either cause or not cause the expression of proteins (pro-inflammatory cytokines) on the cellular level. It was only among those in the tai chi group that we saw the downregulation of inflammation on the cellular level. That's striking because it's this cellular inflammation that is linked to several of the other complications that can result from insomnia.” 3 Is this a reason to look at the benefit of a tai chi intervention for insomnia outside of people with breast cancer? “Yes. I think one thing that is really clear from this data is that we need to think more broadly about how sleep is regulating the immune response—not just inflammation, but other aspects of the immune response. We also found in this particular study in breast cancer survivors that both groups were able to increase antiviral immunity with these interventions. That's really striking in these data. “Then there's the fact that this intervention is available and accessible to a wide population, particularly for older adults. That's one of the reasons I got into tai chi research. I found that many senior centers in the Los Angeles and San Diego area were offering tai chi to seniors and often for free. Older adults were not only going to these tai chi sessions, but they continued to show up again and again.”