There has been much research on the connection between sleep and the risk of developing cancer, but your work is not quite that, is it? Please tell us about your research.

The goal of my research is to improve sleep and waking in patients with advanced cancer. Initially, we examined a sample of patients with advanced cancer in a very methodical, controlled manner so that we could describe quite precisely the nature of the problem. Now, we are exploring the basis for these observations. Once the problem has been described and theoretically explained, one can attempt to predict what would happen if you change a variable to ultimately improve the outcome.

It seems to me that there are both quality of life and deeper health issues related to sleep disorders. Can you discuss each and their importance? How does poor sleep quality impact the course of cancer development and treatment?

Fundamental human needs must be met in order to optimize quality of life. Most people are aware of the importance of proper diet and exercise, but the crucial role that sleep plays is less well appreciated. However, poor sleep has important and negative effects on life quality. Sleep loss actually affects brain functioning and alters the waking experience. By improving the quality of sleep in patients with cancer, their quality of life can improve even though the underlying problem cannot be changed.

Poor sleep quality and short sleep duration have been associated with increased mortality. The results of 1 study suggested that cancer patients with poorer sleep had poorer outcomes compared with those who slept well. Much work remains to be done in this population. However, we know from work in healthy populations that poor sleep is associated with a large number of health problems and patients with cancer are susceptible, and perhaps more vulnerable, to the same problems.

How do you separate the idea of sleep-related disorders from the fuller spectrum of cancer symptom clusters? Many of the sleep disorders in cancer patients are related to more than one issue, such as fatigue, pain, depression, anxiety, etc.

This is an area which I am currently examining.

Depression, fatigue, and pain are common complaints of cancer patients. Poor sleep is also frequently reported. Whether sleep is part of this cluster of symptoms, or represents a common mechanism causing the symptoms to occur together is not well understood. Much previous work has examined a single symptom and not symptom clusters. Part of the problem in studying symptom clusters is the overlap often found in the instruments used for their measurement. This challenge can be addressed using special statistical techniques.

Are there differences in sleep disturbances between patients being treated as outpatients and inpatients?

If a patient has an underlying sleep disorder, that problem will be present whether he/she is an in- or outpatient. Most individuals who are admitted to the hospital will have disturbed sleep due to the environment, stress, pain, and frequent interruptions. New or different medications may also disturb sleep.

Do particular types of cancers cause greater difficulties with sleeping?

The type of cancer is likely to be important because of the underlying pathophysiology.

However, few studies have been conducted in this area and those that have been done contained small sample sizes. In a study of 114 patients (using polysomnography as the primary measure), we found that patients with lung cancer had more severely disturbed sleep than those with other types of cancers.

There is some other work that also suggests lung and breast cancer patient may be more at risk. Clearly, this is a question that remains to be fully explored. Nonetheless, given the prevalence of sleep problems in cancer patients, it behooves the practitioner to explore sleep with them, especially in any kind of palliative care programs.

Are there demographic differences among patients with cancer-related sleep disorders?

There seem to be. In my own work, women have better sleep than men, whites have better sleep than nonwhites, those that have a higher education level did better than those with a lower educational level, and those who lived with another person had greater amounts of sleep than those who lived alone. These findings are very consistent with the demographic differences in the general population.

What do nurses need to know about sleep disorders in patients with cancer? How should these be evaluated?

An understanding of the importance of sleep and the impact of poor sleep can be obtained through self-study and educational programs. However, listening to patients is key. Unfortunately, cancer patients frequently do not bring up sleep issues because caregivers may not pursue the problem with them or do not know what to do about it.

It is important to evaluate a patient's sleep in terms of quantity and quality, and to explore whether the problem involves nocturnal sleep, daytime sleepiness, or both. It is very helpful to talk to the patient's bed partner. Prolonged insomnia, significant snoring or breathing pauses, restlessness or kicking at night, are all problems that may require a referral to a sleep specialist.

Are particular periods in any cancer's course of treatment always worth paying attention to?

The available data suggest that sleep problems may present in cancer patients before the disease is actually diagnosed. Sleep problems are also often reported with chemotherapy, radiation therapy, and surgical therapy. Pain medications, including opioids, can disrupt nocturnal sleep and cause daytime fatigue and sleepiness.

Let's talk more about opioids. Why would one need to worry about sleep problems in patients taking these?

In my research, I've found that patients taking opioids had increased light sleep and less deep sleep. Other work in this area has shown that opioids increase nocturnal arousals and reduce both deep sleep and rapid-eyemovement (REM) sleep. Whether this occurs only in the short- as opposed to long-term is not well described. Daytime sleepiness may also be a significant problem for those taking opioids.

How did you get started in nursing, and how did you arrive at your present area of research interest?

I decided to become a nurse after being hospitalized for a kidney infection when I was about 5. I was cared for by a wonderful nurse and wanted to be just like her.

I became interested in sleep during the years I was a nurse practitioner. Sleep was a tremendous problem for many of my patients and I suspected that medications and/or treatments might be contributing factors. In one research project, for example, we found that lowering the temperature of the dialysis bath used during hemodialysis helped patients sleep better. This sleep-promoting intervention was based on the fact that the body temperature has to drop in order to have optimal sleep. With this, we provided a simple, costeffective, nonpharmacologic intervention, and I became interested in doing that for cancer patients for the same reasons.

Your work has focused on translational science— is that because it is possible to impact patient care more quickly?

Yes, more quickly and perhaps more effectively. Translational research is a natural offshoot of nursing. You're presented with a patient problem, and you go back and look at it to try to address and control it. It's kind of inherent in the way nurses think.

In August 2008, you were named the dean of the University of Rochester School of Nursing. What are your plans for the school and the nursing curriculum?

I am very committed at this stage of my career to developing nursing as a profession and preparing the  nurses of the future. I've been a nurse for more than 30 years—a clinician, an educator, a researcher, and an administrator—and I felt that it was time to focus on developing others and making a difference in nursing. This is a wonderful opportunity for me to do that.

Do you have any advice for the newly minted oncology nurse?

Get enough sleep.

On my downtime, I like to

I really don't have a lot of down time. But I do have a bedtime ritual, and this is something I think everyone should have. In order to sleep optimally, it helps to have a routine that gets your mind conditioned to going to bed. So, for example, a ritual might be showering, getting in your bedclothes, brushing your teeth, and reading for a while. This is helpful in cueing the mind to slow down. You want to avoid things that are very activating, such as bringing work to bed. You need to have a period where you're unwinding, which is very healthy.