Sleep Disturbance in Breast Cancer Under Chemotherapy: A Multifactorial Analysis Emphasizing Psychosocial Dimensions

Sleep Disturbance in Breast Cancer Under Chemotherapy: A Multifactorial Analysis Emphasizing Psychosocial Dimensions | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sleep Disturbance in Breast Cancer Under Chemotherapy: A Multifactorial Analysis Emphasizing Psychosocial Dimensions Hülya Ertas, Burcu Caner, Sibel Oyucu Orhan, Mehmet Sagıroglu, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7278096/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Sleep disturbance is highly prevalent among cancer patients and has been associated with poorer quality of life and potentially adverse oncologic outcomes. Breast cancer patients undergoing chemotherapy are particularly vulnerable due to overlapping physiological, psychological, and treatment-related stressors. This study aimed to determine the prevalence of sleep disturbances and to identify associated clinical and psychosocial factors in this patient population. Methods: A total of 231 breast cancer patients receiving chemotherapy were evaluated. Data on demographic characteristics, menopausal symptoms (Menopause Rating Scale, MRS), anxiety and depression (Hospital Anxiety and Depression Scale, HAD-A and HAD-D), health-related quality of life (Nottingham Health Profile, NHP), and sleep quality (Pittsburgh Sleep Quality Index, PSQI) were collected. Correlation analyses were performed using Pearson coefficients. Logistic regression analyses were conducted to identify predictors of sleep disturbance, defined as a PSQI score ≥ 5. Results: The prevalence of sleep disturbance was 64.5%, with a median PSQI score of 6 (range, 0–19). PSQI scores were moderately correlated with MRS (r = 0.432) and NHP sleep scores (r = 0.461) (both p < 0.001), and weakly but significantly correlated with HAD-A, HAD-D, and multiple NHP subdomains including social isolation and emotional reaction (all p < 0.001). In univariate logistic regression analyses, higher total MRS, HAD-A, NHP social, emotional, sleep, and part 2 scores, as well as a history of psychiatric consultation, were significant predictors of sleep disturbance. However, in multivariate analysis, only the NHP social score remained an independent predictor (OR = 1.02, 95% CI: 1.00–1.04, p = 0.029). Conclusion: Sleep disturbance is common among breast cancer patients undergoing chemotherapy and appears to be more strongly associated with psychosocial dimensions, particularly social isolation, than with traditional biomedical variables. These findings underscore the importance of incorporating psychosocial assessments and interventions into the supportive care of this population to potentially mitigate sleep-related morbidity. Breast Neoplasms Sleep Wake Disorders Menopause Anxiety Depression INTRODUCTION Breast cancer remains the most prevalent malignancy among women worldwide, and its treatment often entails a prolonged, arduous, and psychologically taxing course. Throughout this period, patients are confronted with a myriad of challenges, including treatment-related side effects, alterations in body image, fears surrounding mortality, and substantial financial burdens. Sleep disturbance constitutes a significant component of this multifaceted burden. Notably, one study reported that approximately 50% of patients diagnosed with breast cancer experienced insomnia at some point during their treatment journey, with symptoms persisting into the fifth year post-diagnosis(1,2). Sleep plays an indispensable role in maintaining physiological homeostasis, a function that is remarkably conserved across the phylogenetic spectrum(3). Cancer-related disruptions in metabolism, immune function, and endocrine pathways are known to influence the regulatory mechanisms of sleep. Sleep disorders are broadly categorized into seven distinct groups, with insomnia representing the most prevalent type. Insomnia is generally characterized by difficulties in initiating and maintaining sleep, early morning awakenings, and nonrestorative or poor-quality sleep. Although polysomnography remains the gold standard for the classification and diagnosis of sleep disorders, it is not routinely required for cases of insomnia. Instead, a thorough clinical history and physical examination, often supplemented by sleep diaries, are typically sufficient to exclude secondary causes(4). Consequently, several validated indices have been developed to assess sleep quality. Among these, the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) are most frequently utilized, with reported sensitivities and specificities exceeding 85% for the detection of insomnia (5). The PSQI, in particular, has emerged as the preferred instrument in studies involving cancer populations . The primary objective of our study was to evaluate the prevalence of sleep disturbances and to identify the associated factors in patients with breast cancer undergoing chemotherapy. MATERIAL-METHODS Our survey study was conducted in Ali Osman Sönmez Oncology Hospital and Bursa City Hospital between October 2022 and January 2023, after the approval of the ethics committee. Patients over the age of 18, diagnosed with breast cancer and receiving active were included in the study. Questionnaires were asked to the patients on a voluntary basis before or after the examination when they applied for chemotherapy, and they were asked to leave the questionnaire to the relevant researcher after completion. The questionnaire included of 5 parts. In the first part of the study, questions about demographic characteristics were asked to the patients. Part 2 contained the questions of the PSQI questionnaire, there was following section related to the Anxiety and Depression scale. The last 2 parts consist of Nottingham health profile and Menopause Measurement scale. PSQI was a scale with 24 questions. 19 questions consisted of questions to be answered by the patient herself, and the last 5 questions to be answered by her partner or roommate. Questions answered by the partner or roommate were not included when calculating the index score. Self-evaluation questions included items related to sleep quality. Each item was evaluated with 0–3 points. The 18 scored questions of the scale were grouped as 7 component points. The total score of the 7 components was calculated as the total score of the index. Patients with a total score greater than 5 were considered to have "poor sleep quality-insomnia". Hospital anxiety and depression scale (HAD) was a scale consisting of 14 questions. Each question was evaluated with a score between 0–3. While 7 of the 14 questions were on the depression scale, the other 7 were measuring the anxiety level. When the total score is evaluated, it is between 0–7; normal, between 8–10 was considered as borderline, and above 11 was considered pathological. Menopause measurement scale consisted of 11 questions about menopause symptoms. These were hot flushes, palpitations, insomnia, melancholia, nervousness, anxiety, physical and mental weakness, sexual problems,urinary problems,dryness in the vagina and arthralgia or myalgia. Each symptom was rated from 0 to 4 according to severity. The scores were weighted and a total sum was calculated with a higher score indicating a worse quality of life. Nottingham health profile had two parts. The first included 38 true/false items measuring six domains: sleep, physical mobility, energy, pain, emotional reactions, and social isolation. Items were scaled in order to allow them to vary between 0 and 100 within each section. The second part of the NHP included seven phrases related to the areas of life most influenced by health: employment, household activities, social life, home life, sex life, hobbies and interests, and holidays. The respondent defined whether or not a health condition had affected her life in these areas. Statistical analysis was performed using SPSS version 26. Data were evaluated using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Quantitative data are presented as median, minimum, and maximum values. Correlation analyses were performed using the Pearson's rank-sum test. Sleep disturbance and demographic characteristics were assessed using the independent t-test, Wilcoxon Rank-Sum test, chi-square test, and Fisher's Exact test. Pairwise comparisons were made using the two-proportion z test with Bonferroni correction. P < 0.05 was considered statistically significant. Logistic regression was applied to evaluate the factors causing sleep disturbance according to the PSQI. Values with a p < 0.20 in the univariate analysis were included in the multivariate analysis. P < 0.05 was considered statistically significant in the multivariate analysis. RESULTS A total of 231 patients diagnosed with breast cancer and receiving chemotherapy were enrolled in this study. The median age was 52 years (range, 29–87). Most patients were married (77.1%) and had less than a high school education (74.4%). Approximately 27% of patients were employed. The median body mass index (BMI) was 27.8 kg/m² (range, 17.6–42.5), with 66.6% classified as overweight or obese. Comorbid conditions were reported in 39.8% of patients, with hypertension (25.1%) and diabetes mellitus (12.6%) being the most prevalent. Sleep disturbances, as defined by a PSQI score ≥5, were identified in 149 patients (64.5%). The median PSQI score was 6 (range, 0–19). Patients with a history of psychiatric consultation had a significantly higher prevalence of sleep disturbances (p=0.002). Similarly, sleep disturbances tended to be more frequent among smokers, although this did not reach statistical significance (p=0.051). We showed this detail in Table 1. When evaluated by menopausal symptoms, patients with moderate and severe MRS scores demonstrated significantly higher rates of sleep disturbance (p<0.005). Subscale analysis of the Nottingham Health Profile (NHP) revealed that social isolation (p<0.005), emotional reaction (p=0.026), pain (p=0.034), and sleep dimensions (p<0.005), as well as the NHP part 2 score (p=0.002), were significantly associated with sleep disturbances. Higher HAD-A scores were also associated with increased prevalence of sleep disturbance (p=0.014). Correlation analysis demonstrated that PSQI scores were moderately correlated with MRS scores (r=0.432, p<0.001) and NHP sleep scores (r=0.461, p<0.001). Weak but statistically significant correlations were observed between PSQI scores and NHP social isolation (r=0.364), physical mobility (r=0.226), emotional reaction (r=0.349), energy (r=0.309), pain (r=0.280), NHP part 2 (r=0.357), HAD-A (r=0.284), and HAD-D (r=0.233) scores (all p<0.001). In univariate logistic regression analysis, total MRS score (OR=1.11, 95% CI: 1.06–1.16, p<0.001), HAD-A score (OR=1.06, 95% CI: 1.00–1.14, p=0.046), NHP social score (OR=1.02, 95% CI: 1.01–1.04, p=0.001), NHP emotional score (OR=1.01, 95% CI: 1.00–1.03, p=0.019), NHP sleep score (OR=1.02, 95% CI: 1.01–1.03, p<0.001), and NHP part 2 score (OR=1.39, 95% CI: 1.12–1.71, p=0.002) emerged as significant predictors of sleep disturbance. Additionally, the presence of psychiatric consultation (OR=2.84, 95% CI: 1.45–5.54, p=0.002) and elevated HAD-A group classification (borderline and abnormal) were also significant. However, in the multivariate logistic regression model, only the NHP social score remained an independent predictor of sleep disturbance (OR=1.02, 95% CI: 1.00–1.04, p=0.029). Other variables, including MRS, HAD-A, and smoking, did not retain statistical significance. DISCUSSION Sleep is a complex neurobiological state centrally orchestrated by the brain and regulated across local, regional, and global levels through intricate molecular and cellular mechanisms. The activity of specific brainstem neuromodulatory systems determines which combinations of neuronal pathways are engaged, thereby influencing the emergence of wakefulness, rapid eye movement (REM) sleep, or non-REM (NREM) sleep(6). Despite substantial progress, it remains unclear precisely how the brain integrates external sensory inputs with internal signals derived from homeostatic and circadian processes to establish the prevailing state of arousal. Disruptions in circadian synchrony impair sleep homeostasis and are implicated in the pathogenesis of various disease states, including cancer. Cancer is a quintessential multisystem disease capable of perturbing multiple tissues and organs. To evade immune surveillance and fulfill heightened metabolic demands, malignant cells actively remodel their microenvironment by modulating the function of neighboring stromal cells—such as T lymphocytes, fibroblasts, and macrophages—as well as distant organs including the liver and brain. Intriguingly, Scott et al. reported that cancer patients and astronauts manifest comparable multisystem physiological toxicities arising from analogous predisposing factors and the direct or indirect consequences of either anticancer therapies or spaceflight exposure. Indeed, the association between sleep disturbance and cancer has frequently been characterized as a “chicken or the egg” paradigm, wherein malignancy precipitates sleep disruption, while conversely, poor sleep may potentiate oncogenesis and tumor progression(7). This bidirectional interplay complicates efforts to disentangle causality in cancer-associated sleep disorders. In the present study evaluating sleep disturbance in breast cancer patients undergoing chemotherapy, we observed a notably high prevalence of impaired sleep quality, with approximately 65% of patients meeting the threshold on the PSQI. This finding aligns with previous reports documenting sleep disturbances in 30% to 75% of cancer patients, contingent upon cancer type, stage, and treatment regimen(8,9). Our data demonstrated that menopausal symptoms, as assessed by the MRS, were significantly associated with reduced sleep quality. Both the total MRS score and graded severity categories correlated with PSQI scores, and moderate-to-severe menopausal symptoms substantially increased the odds of sleep disturbance in univariate analyses. This is consistent with existing literature implicating vasomotor and psychological sequelae of menopause in the exacerbation of insomnia among breast cancer survivors(10,11). However, this association did not persist in multivariate models, potentially attributable to collinearity with overlapping psychosocial constructs. Furthermore, anxiety (quantified by HAD-A scores) and a history of psychiatric consultation were also linked to sleep disturbance in univariate analyses. The observed weak-to-moderate correlations between PSQI scores and both HAD-A and HAD-D underscore the established bidirectional relationship between psychological distress and sleep disruption in oncology populations(12). Nonetheless, these parameters did not emerge as independent predictors in multivariate logistic regression, suggesting their impact on sleep may be mediated by broader domains of health-related quality of life. Of particular interest, our findings revealed that the NHP subscales for social isolation and emotional reaction exhibited significant correlations with PSQI scores, and the NHP part 2 summary score remained an independent predictor of sleep disturbance in multivariate analysis. This emphasizes the pivotal role of psychosocial health in modulating sleep quality among breast cancer patients, beyond the direct influences of disease or treatment. These observations corroborate prior studies highlighting the influence of perceived social support, emotional resilience, and overall quality of life on sleep architecture in oncology settings(13,14). Contrary to our expectations, traditional biomedical factors such as age, body mass index, comorbid disease burden, and oncologic treatment phase (neoadjuvant, adjuvant, or metastatic) were not significantly associated with sleep disturbance in this cohort. Although smoking approached significance in univariate models, it did not retain predictive value in adjusted analyses. Collectively, these results suggest that psychosocial determinants may exert a more profound influence on sleep pathology in this population than classical clinical variables. The strengths of this study include a comparatively large, homogeneously treated cohort and the employment of validated, multidimensional instruments to comprehensively assess sleep quality, menopausal symptoms, psychological distress, and health-related quality of life. However, certain limitations merit acknowledgment. The cross-sectional design inherently precludes causal inference, reliance on self-reported measures may introduce recall or reporting bias, and despite multivariate adjustments, residual confounding cannot be entirely ruled out. Future longitudinal studies are imperative to delineate the temporal interrelationships among menopausal symptomatology, psychological distress, quality of life, and sleep disturbance. Additionally, interventional trials targeting modifiable psychosocial risk factors may offer promising avenues to ameliorate sleep disturbances and thereby enhance survivorship outcomes. Given the growing recognition that sleep not only reflects but also actively contributes to disease processes, ongoing elucidation of sleep-regulating neurobiological circuits and molecular pathways holds substantial promise for improving quality of life in cancer patients. Declarations STATEMENT OF ETHICS This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Bursa City Hospital (Decision No: 2022-21/10, Date: 12.10.2022). All participants were informed about the objectives and procedures of the study, and written informed consent was obtained from each participant prior to inclusion. Participation in the study was entirely voluntary, and confidentiality of personal data was strictly maintained. Special care was taken to ensure that patients undergoing cancer treatment, who may be considered a vulnerable population, were not subjected to coercion, and that they had full autonomy in deciding to participate. DATA AVAILABILITY The data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author H.E. CONFLICT OF INTEREST STATEMENT The authors have no conflicts of interest to declare. FUNDING SOURCES This study was not supported by any sponsor or funder. Acknowledgement (optional) Conflict of Interest Statement The authors have no conflicts of interest to declare. Funding Sources This study was not supported by any sponsor or funder. Author Contributions Hulya Ertas: conceptualization, methodology, data curation, formal analysis, investigation, writing - original draft; Burcu Caner: methodology, data curation, formal analysis, investigation, writing - review & editing; Sibel Oyucu Orhan: data curation, validation, writing - review & editing, supervision; Mehmet Sagiroglu: methodology, data curation, writing - review & editing, supervision; Arife Ulas: methodology, data curation, writing - review & editing, supervision. References Otte JL, Carpenter JS, Manchanda S, Rand KL, Skaar TC, Weaver M, et al. Systematic review of sleep disorders in cancer patients: can the prevalence estimates be compared? Support Care Cancer. 2015;23(3):985-1000. Fleming L, Randell K, Stewart E, Espie CA, Morrison DS, Lawless C, et al. Insomnia in breast cancer: a prospective observational study. Psychooncology. 2019;28(3):468-74. Zielinski MR, McKenna JT, McCarley RW. Functions and mechanisms of sleep. AIMS Neurosci. 2016;3(1):67-104. Becker PM. Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Psychiatr Clin North Am. 2006;29(4):855-70. American Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014. Zielinski MR, McKenna JT, McCarley RW. Neuronal mechanisms for sleep/wake regulation and modulatory drive. Neurotherapeutics. 2012;9(4):730-42. Berisha A, Shutkind K, Borniger JC. Sleep disruption and cancer: chicken or the egg? Front Neurosci. 2021;15:691372. Savard J, Simard S, Ivers H, Morin CM. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol. 2005;23(25):6083-96. Fiorentino L, Rissling M, Liu L, Ancoli-Israel S. The symptom cluster of sleep, fatigue and depressive symptoms in breast cancer patients: severity of the problem and treatment options. Drug Discov Today Dis Models. 2011;8(4):167-73. Carpenter JS ,Andrykowski MA, Freedman RR, Munn RK. Feasibility and psychometrics of an ambulatory hot flash monitoring device. Menopause. 1999;6(3):20915. Reinertsen KV, Cvancarova M, Loge JH, Edvardsen H, Wist E, Fosså SD. Predictors and course of chronic fatigue in long-term breast cancer survivors. J Cancer Surviv. 2010;4(4):405-14. 12. Palesh OG, Roscoe JA, Mustian KM, Roth T, Savard J, Ancoli-Israel S, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center–Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292-8. Otte JL, Carpenter JS, Manchanda S, Rand KL, Skaar TC, Weaver M. Systematic review of sleep disorders in cancer patients: can the prevalence estimates be compared? Support Care Cancer. 2015;23(3):985-1000. Garland SN, Johnson JA, Savard J, Gehrman P, Perlis M, Carlson L, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113-24. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files regresyontablosu.docx korelasyontablosu.docx uyku2.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7278096","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":497703623,"identity":"3934bcb8-a3f1-4632-b174-9cd4d346d384","order_by":0,"name":"Hülya Ertas","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYDCCAzwMDA+AND+Ik1BArJYEIC3ZANJiQIoWgwMgHjFa+G6fPSaR2GaXuPn86sQPDwwY5PnFDuDXInkuLw2oJTlx2423myWADjOcOTsBvxaDMzxmQC3MQC1nN4C0JBjcJk5LfeLmGWc3/yBFy+HEDfy924izRfIMj7FFwrnjxjNu8G6zSDCQIOwXvjM8hjc+lFXL9vef3XzzR4WNPL80AS1gwMjG4NggAVYpQYRyMPjDYM/Af4BY1aNgFIyCUTDSAACYbEiZ9gRxHAAAAABJRU5ErkJggg==","orcid":"","institution":"Ali Osman Sonmez Oncology Hospital","correspondingAuthor":true,"prefix":"","firstName":"Hülya","middleName":"","lastName":"Ertas","suffix":""},{"id":497703624,"identity":"d2e71f02-d379-41e7-ace8-c3b1c0bf6b5b","order_by":1,"name":"Burcu Caner","email":"","orcid":"","institution":"Ataturk State Hospital","correspondingAuthor":false,"prefix":"","firstName":"Burcu","middleName":"","lastName":"Caner","suffix":""},{"id":497703625,"identity":"7407f220-4fb4-4dd1-8cfa-7ba79d7a7bf7","order_by":2,"name":"Sibel Oyucu Orhan","email":"","orcid":"","institution":"Bursa City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Sibel","middleName":"Oyucu","lastName":"Orhan","suffix":""},{"id":497703626,"identity":"ab19bb23-e6eb-45ed-a65c-9f5cc0bf94c6","order_by":3,"name":"Mehmet Sagıroglu","email":"","orcid":"","institution":"bursa medicalpark hospital","correspondingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"Sagıroglu","suffix":""},{"id":497703627,"identity":"81a81c11-bbb5-403a-b87e-3ac1d4d30d87","order_by":4,"name":"Arife Ulas","email":"","orcid":"","institution":"Bursa City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Arife","middleName":"","lastName":"Ulas","suffix":""}],"badges":[],"createdAt":"2025-08-02 12:08:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7278096/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7278096/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":105892867,"identity":"abdfa93f-133a-4897-8889-e26dffd1a43d","added_by":"auto","created_at":"2026-04-01 08:14:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":338202,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7278096/v1/54ff44d5-b97c-4085-8354-8bebdd43614d.pdf"},{"id":88976423,"identity":"8af533fc-5606-4c36-bb10-e5f9c5bd7fa0","added_by":"auto","created_at":"2025-08-13 10:33:53","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":20682,"visible":true,"origin":"","legend":"","description":"","filename":"regresyontablosu.docx","url":"https://assets-eu.researchsquare.com/files/rs-7278096/v1/d5e277a29f56b09f1f4deb1e.docx"},{"id":88976424,"identity":"c8307102-6b9b-4ef2-a1d1-6408eb38be70","added_by":"auto","created_at":"2025-08-13 10:33:53","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19765,"visible":true,"origin":"","legend":"","description":"","filename":"korelasyontablosu.docx","url":"https://assets-eu.researchsquare.com/files/rs-7278096/v1/ff7d63b662b4f84857459276.docx"},{"id":88976425,"identity":"67616965-51e0-43b4-936d-dd6ab887f3dd","added_by":"auto","created_at":"2025-08-13 10:33:53","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":33871,"visible":true,"origin":"","legend":"","description":"","filename":"uyku2.docx","url":"https://assets-eu.researchsquare.com/files/rs-7278096/v1/fcbf2b51dae87658b0196b8b.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sleep Disturbance in Breast Cancer Under Chemotherapy: A Multifactorial Analysis Emphasizing Psychosocial Dimensions","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eBreast cancer remains the most prevalent malignancy among women worldwide, and its treatment often entails a prolonged, arduous, and psychologically taxing course. Throughout this period, patients are confronted with a myriad of challenges, including treatment-related side effects, alterations in body image, fears surrounding mortality, and substantial financial burdens. Sleep disturbance constitutes a significant component of this multifaceted burden. Notably, one study reported that approximately 50% of patients diagnosed with breast cancer experienced insomnia at some point during their treatment journey, with symptoms persisting into the fifth year post-diagnosis(1,2). Sleep plays an indispensable role in maintaining physiological homeostasis, a function that is remarkably conserved across the phylogenetic spectrum(3). Cancer-related disruptions in metabolism, immune function, and endocrine pathways are known to influence the regulatory mechanisms of sleep.\u003c/p\u003e\u003cp\u003eSleep disorders are broadly categorized into seven distinct groups, with insomnia representing the most prevalent type. Insomnia is generally characterized by difficulties in initiating and maintaining sleep, early morning awakenings, and nonrestorative or poor-quality sleep. Although polysomnography remains the gold standard for the classification and diagnosis of sleep disorders, it is not routinely required for cases of insomnia. Instead, a thorough clinical history and physical examination, often supplemented by sleep diaries, are typically sufficient to exclude secondary causes(4). Consequently, several validated indices have been developed to assess sleep quality. Among these, the Insomnia Severity Index (ISI) and the Pittsburgh Sleep Quality Index (PSQI) are most frequently utilized, with reported sensitivities and specificities exceeding 85% for the detection of insomnia (5). The PSQI, in particular, has emerged as the preferred instrument in studies involving cancer populations .\u003c/p\u003e\u003cp\u003eThe primary objective of our study was to evaluate the prevalence of sleep disturbances and to identify the associated factors in patients with breast cancer undergoing chemotherapy.\u003c/p\u003e"},{"header":"MATERIAL-METHODS","content":"\u003cp\u003e Our survey study was conducted in Ali Osman Sönmez Oncology Hospital and Bursa City Hospital between October 2022 and January 2023, after the approval of the ethics committee. Patients over the age of 18, diagnosed with breast cancer and receiving active were included in the study. Questionnaires were asked to the patients on a voluntary basis before or after the examination when they applied for chemotherapy, and they were asked to leave the questionnaire to the relevant researcher after completion.\u003c/p\u003e\u003cp\u003eThe questionnaire included of 5 parts. In the first part of the study, questions about demographic characteristics were asked to the patients. Part 2 contained the questions of the PSQI questionnaire, there was following section related to the Anxiety and Depression scale. The last 2 parts consist of Nottingham health profile and Menopause Measurement scale.\u003c/p\u003e\u003cp\u003ePSQI was a scale with 24 questions. 19 questions consisted of questions to be answered by the patient herself, and the last 5 questions to be answered by her partner or roommate. Questions answered by the partner or roommate were not included when calculating the index score. Self-evaluation questions included items related to sleep quality. Each item was evaluated with 0–3 points. The 18 scored questions of the scale were grouped as 7 component points. The total score of the 7 components was calculated as the total score of the index. Patients with a total score greater than 5 were considered to have \"poor sleep quality-insomnia\".\u003c/p\u003e\u003cp\u003eHospital anxiety and depression scale (HAD) was a scale consisting of 14 questions. Each question was evaluated with a score between 0–3. While 7 of the 14 questions were on the depression scale, the other 7 were measuring the anxiety level. When the total score is evaluated, it is between 0–7; normal, between 8–10 was considered as borderline, and above 11 was considered pathological.\u003c/p\u003e\u003cp\u003eMenopause measurement scale consisted of 11 questions about menopause symptoms. These were hot flushes, palpitations, insomnia, melancholia, nervousness, anxiety, physical and mental weakness, sexual problems,urinary problems,dryness in the vagina and arthralgia or myalgia. Each symptom was rated from 0 to 4 according to severity. The scores were weighted and a total sum was calculated with a higher score indicating a worse quality of life.\u003c/p\u003e\u003cp\u003eNottingham health profile had two parts. The first included 38 true/false items measuring six domains: sleep, physical mobility, energy, pain, emotional reactions, and social isolation. Items were scaled in order to allow them to vary between 0 and 100 within each section. The second part of the NHP included seven phrases related to the areas of life most influenced by health: employment, household activities, social life, home life, sex life, hobbies and interests, and holidays. The respondent defined whether or not a health condition had affected her life in these areas.\u003c/p\u003e\u003cp\u003eStatistical analysis was performed using SPSS version 26. Data were evaluated using the Kolmogorov-Smirnov and Shapiro-Wilk tests. Quantitative data are presented as median, minimum, and maximum values. Correlation analyses were performed using the Pearson's rank-sum test. Sleep disturbance and demographic characteristics were assessed using the independent t-test, Wilcoxon Rank-Sum test, chi-square test, and Fisher's Exact test. Pairwise comparisons were made using the two-proportion z test with Bonferroni correction. P \u0026lt; 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003eLogistic regression was applied to evaluate the factors causing sleep disturbance according to the PSQI. Values with a p \u0026lt; 0.20 in the univariate analysis were included in the multivariate analysis. P \u0026lt; 0.05 was considered statistically significant in the multivariate analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 231 patients diagnosed with breast cancer and receiving chemotherapy were enrolled in this study. The median age was 52 years (range, 29\u0026ndash;87). Most patients were married (77.1%) and had less than a high school education (74.4%). Approximately 27% of patients were employed. The median body mass index (BMI) was 27.8 kg/m\u0026sup2; (range, 17.6\u0026ndash;42.5), with 66.6% classified as overweight or obese. Comorbid conditions were reported in 39.8% of patients, with hypertension (25.1%) and diabetes mellitus (12.6%) being the most prevalent. Sleep disturbances, as defined by a PSQI score \u0026ge;5, were identified in 149 patients (64.5%). The median PSQI score was 6 (range, 0\u0026ndash;19). Patients with a history of psychiatric consultation had a significantly higher prevalence of sleep disturbances (p=0.002). Similarly, sleep disturbances tended to be more frequent among smokers, although this did not reach statistical significance (p=0.051). We showed this detail in Table 1.\u003c/p\u003e\n\u003cp\u003eWhen evaluated by menopausal symptoms, patients with moderate and severe MRS scores demonstrated significantly higher rates of sleep disturbance (p\u0026lt;0.005). Subscale analysis of the Nottingham Health Profile (NHP) revealed that social isolation (p\u0026lt;0.005), emotional reaction (p=0.026), pain (p=0.034), and sleep dimensions (p\u0026lt;0.005), as well as the NHP part 2 score (p=0.002), were significantly associated with sleep disturbances. Higher HAD-A scores were also associated with increased prevalence of sleep disturbance (p=0.014). Correlation analysis demonstrated that PSQI scores were moderately correlated with MRS scores (r=0.432, p\u0026lt;0.001) and NHP sleep scores (r=0.461, p\u0026lt;0.001). Weak but statistically significant correlations were observed between PSQI scores and NHP social isolation (r=0.364), physical mobility (r=0.226), emotional reaction (r=0.349), energy (r=0.309), pain (r=0.280), NHP part 2 (r=0.357), HAD-A (r=0.284), and HAD-D (r=0.233) scores (all p\u0026lt;0.001). In univariate logistic regression analysis, total MRS score (OR=1.11, 95% CI: 1.06\u0026ndash;1.16, p\u0026lt;0.001), HAD-A score (OR=1.06, 95% CI: 1.00\u0026ndash;1.14, p=0.046), NHP social score (OR=1.02, 95% CI: 1.01\u0026ndash;1.04, p=0.001), NHP emotional score (OR=1.01, 95% CI: 1.00\u0026ndash;1.03, p=0.019), NHP sleep score (OR=1.02, 95% CI: 1.01\u0026ndash;1.03, p\u0026lt;0.001), and NHP part 2 score (OR=1.39, 95% CI: 1.12\u0026ndash;1.71, p=0.002) emerged as significant predictors of sleep disturbance. Additionally, the presence of psychiatric consultation (OR=2.84, 95% CI: 1.45\u0026ndash;5.54, p=0.002) and elevated HAD-A group classification (borderline and abnormal) were also significant. However, in the multivariate logistic regression model, only the NHP social score remained an independent predictor of sleep disturbance (OR=1.02, 95% CI: 1.00\u0026ndash;1.04, p=0.029). Other variables, including MRS, HAD-A, and smoking, did not retain statistical significance.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eSleep is a complex neurobiological state centrally orchestrated by the brain and regulated across local, regional, and global levels through intricate molecular and cellular mechanisms. The activity of specific brainstem neuromodulatory systems determines which combinations of neuronal pathways are engaged, thereby influencing the emergence of wakefulness, rapid eye movement (REM) sleep, or non-REM (NREM) sleep(6). Despite substantial progress, it remains unclear precisely how the brain integrates external sensory inputs with internal signals derived from homeostatic and circadian processes to establish the prevailing state of arousal. Disruptions in circadian synchrony impair sleep homeostasis and are implicated in the pathogenesis of various disease states, including cancer.\u003c/p\u003e\n\u003cp\u003eCancer is a quintessential multisystem disease capable of perturbing multiple tissues and organs. To evade immune surveillance and fulfill heightened metabolic demands, malignant cells actively remodel their microenvironment by modulating the function of neighboring stromal cells\u0026mdash;such as T lymphocytes, fibroblasts, and macrophages\u0026mdash;as well as distant organs including the liver and brain. Intriguingly, Scott et al. reported that cancer patients and astronauts manifest comparable multisystem physiological toxicities arising from analogous predisposing factors and the direct or indirect consequences of either anticancer therapies or spaceflight exposure. Indeed, the association between sleep disturbance and cancer has frequently been characterized as a \u0026ldquo;chicken or the egg\u0026rdquo; paradigm, wherein malignancy precipitates sleep disruption, while conversely, poor sleep may potentiate oncogenesis and tumor progression(7). This bidirectional interplay complicates efforts to disentangle causality in cancer-associated sleep disorders.\u003c/p\u003e\n\u003cp\u003eIn the present study evaluating sleep disturbance in breast cancer patients undergoing chemotherapy, we observed a notably high prevalence of impaired sleep quality, with approximately 65% of patients meeting the threshold on the PSQI. This finding aligns with previous reports documenting sleep disturbances in 30% to 75% of cancer patients, contingent upon cancer type, stage, and treatment regimen(8,9).\u003c/p\u003e\n\u003cp\u003eOur data demonstrated that menopausal symptoms, as assessed by the MRS, were significantly associated with reduced sleep quality. Both the total MRS score and graded severity categories correlated with PSQI scores, and moderate-to-severe menopausal symptoms substantially increased the odds of sleep disturbance in univariate analyses. This is consistent with existing literature implicating vasomotor and psychological sequelae of menopause in the exacerbation of insomnia among breast cancer survivors(10,11). However, this association did not persist in multivariate models, potentially attributable to collinearity with overlapping psychosocial constructs.\u003c/p\u003e\n\u003cp\u003eFurthermore, anxiety (quantified by HAD-A scores) and a history of psychiatric consultation were also linked to sleep disturbance in univariate analyses. The observed weak-to-moderate correlations between PSQI scores and both HAD-A and HAD-D underscore the established bidirectional relationship between psychological distress and sleep disruption in oncology populations(12). Nonetheless, these parameters did not emerge as independent predictors in multivariate logistic regression, suggesting their impact on sleep may be mediated by broader domains of health-related quality of life.\u003c/p\u003e\n\u003cp\u003eOf particular interest, our findings revealed that the NHP subscales for social isolation and emotional reaction exhibited significant correlations with PSQI scores, and the NHP part 2 summary score remained an independent predictor of sleep disturbance in multivariate analysis. This emphasizes the pivotal role of psychosocial health in modulating sleep quality among breast cancer patients, beyond the direct influences of disease or treatment. These observations corroborate prior studies highlighting the influence of perceived social support, emotional resilience, and overall quality of life on sleep architecture in oncology settings(13,14).\u003c/p\u003e\n\u003cp\u003eContrary to our expectations, traditional biomedical factors such as age, body mass index, comorbid disease burden, and oncologic treatment phase (neoadjuvant, adjuvant, or metastatic) were not significantly associated with sleep disturbance in this cohort. Although smoking approached significance in univariate models, it did not retain predictive value in adjusted analyses. Collectively, these results suggest that psychosocial determinants may exert a more profound influence on sleep pathology in this population than classical clinical variables.\u003c/p\u003e\n\u003cp\u003eThe strengths of this study include a comparatively large, homogeneously treated cohort and the employment of validated, multidimensional instruments to comprehensively assess sleep quality, menopausal symptoms, psychological distress, and health-related quality of life. However, certain limitations merit acknowledgment. The cross-sectional design inherently precludes causal inference, reliance on self-reported measures may introduce recall or reporting bias, and despite multivariate adjustments, residual confounding cannot be entirely ruled out.\u003c/p\u003e\n\u003cp\u003eFuture longitudinal studies are imperative to delineate the temporal interrelationships among menopausal symptomatology, psychological distress, quality of life, and sleep disturbance. Additionally, interventional trials targeting modifiable psychosocial risk factors may offer promising avenues to ameliorate sleep disturbances and thereby enhance survivorship outcomes. Given the growing recognition that sleep not only reflects but also actively contributes to disease processes, ongoing elucidation of sleep-regulating neurobiological circuits and molecular pathways holds substantial promise for improving quality of life in cancer patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eSTATEMENT OF ETHICS\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Ethics Committee of Bursa City Hospital (Decision No: 2022-21/10, Date: 12.10.2022). All participants were informed about the objectives and procedures of the study, and written informed consent was obtained from each participant prior to inclusion. Participation in the study was entirely voluntary, and confidentiality of personal data was strictly maintained. Special care was taken to ensure that patients undergoing cancer treatment, who may be considered a vulnerable population, were not subjected to coercion, and that they had full autonomy in deciding to participate.\u003c/p\u003e\n\u003cp\u003eDATA AVAILABILITY\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are not publicly available due to their containing information that could compromise the privacy of research participants but are available from the corresponding author H.E.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCONFLICT OF INTEREST STATEMENT\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003eFUNDING SOURCES\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cspan id=\"_Toc472330563\"\u003eAcknowledgement (optional)\u003c/span\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp id=\"_Toc472330565\"\u003e\u003cstrong\u003eConflict of Interest Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cspan id=\"_Toc472330566\"\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eThis study was not supported by any sponsor or funder.\u003c/p\u003e\n\u003cp id=\"_Toc472330568\"\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHulya Ertas: conceptualization, methodology, data curation, formal analysis, investigation, writing - original draft; Burcu Caner: \u0026nbsp;methodology, data curation, formal analysis, investigation, writing - review \u0026amp; editing; Sibel Oyucu Orhan: data curation, validation, writing - review \u0026amp; editing, supervision; Mehmet Sagiroglu: methodology, data curation, writing - review \u0026amp; editing, supervision; Arife Ulas: methodology, data curation, writing - review \u0026amp; editing, supervision.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOtte JL, Carpenter JS, Manchanda S, Rand KL, Skaar TC, Weaver M, et al. Systematic review of sleep disorders in cancer patients: can the prevalence estimates be compared? Support Care Cancer. 2015;23(3):985-1000.\u003c/li\u003e\n\u003cli\u003eFleming L, Randell K, Stewart E, Espie CA, Morrison DS, Lawless C, et al. Insomnia in breast cancer: a prospective observational study. Psychooncology. 2019;28(3):468-74. \u003c/li\u003e\n\u003cli\u003eZielinski MR, McKenna JT, McCarley RW. Functions and mechanisms of sleep. AIMS Neurosci. 2016;3(1):67-104.\u003c/li\u003e\n\u003cli\u003eBecker PM. Insomnia: prevalence, impact, pathogenesis, differential diagnosis, and evaluation. Psychiatr Clin North Am. 2006;29(4):855-70.\u003c/li\u003e\n\u003cli\u003eAmerican Academy of Sleep Medicine. International Classification of Sleep Disorders. 3rd ed. Darien, IL: American Academy of Sleep Medicine; 2014.\u003c/li\u003e\n\u003cli\u003eZielinski MR, McKenna JT, McCarley RW. Neuronal mechanisms for sleep/wake regulation and modulatory drive. Neurotherapeutics. 2012;9(4):730-42.\u003c/li\u003e\n\u003cli\u003eBerisha A, Shutkind K, Borniger JC. Sleep disruption and cancer: chicken or the egg? Front Neurosci. 2021;15:691372.\u003c/li\u003e\n\u003cli\u003eSavard J, Simard S, Ivers H, Morin CM. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol. 2005;23(25):6083-96.\u003c/li\u003e\n\u003cli\u003eFiorentino L, Rissling M, Liu L, Ancoli-Israel S. The symptom cluster of sleep, fatigue and depressive symptoms in breast cancer patients: severity of the problem and treatment options. Drug Discov Today Dis Models. 2011;8(4):167-73.\u003c/li\u003e\n\u003cli\u003eCarpenter JS ,Andrykowski MA, Freedman RR, Munn RK. Feasibility and psychometrics of an ambulatory hot flash monitoring device. Menopause. 1999;6(3):20915.\u003c/li\u003e\n\u003cli\u003eReinertsen KV, Cvancarova M, Loge JH, Edvardsen H, Wist E, Foss\u0026aring; SD. Predictors and course of chronic fatigue in long-term breast cancer survivors. J Cancer Surviv. 2010;4(4):405-14.\u003cbr\u003e 12. Palesh OG, Roscoe JA, Mustian KM, Roth T, Savard J, Ancoli-Israel S, et al. Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center\u0026ndash;Community Clinical Oncology Program. J Clin Oncol. 2010;28(2):292-8.\u003c/li\u003e\n\u003cli\u003eOtte JL, Carpenter JS, Manchanda S, Rand KL, Skaar TC, Weaver M. Systematic review of sleep disorders in cancer patients: can the prevalence estimates be compared? Support Care Cancer. 2015;23(3):985-1000.\u003c/li\u003e\n\u003cli\u003eGarland SN, Johnson JA, Savard J, Gehrman P, Perlis M, Carlson L, et al. Sleeping well with cancer: a systematic review of cognitive behavioral therapy for insomnia in cancer patients. Neuropsychiatr Dis Treat. 2014;10:1113-24.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Breast Neoplasms, Sleep Wake Disorders, Menopause, Anxiety, Depression","lastPublishedDoi":"10.21203/rs.3.rs-7278096/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7278096/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eSleep disturbance is highly prevalent among cancer patients and has been associated with poorer quality of life and potentially adverse oncologic outcomes. Breast cancer patients undergoing chemotherapy are particularly vulnerable due to overlapping physiological, psychological, and treatment-related stressors. This study aimed to determine the prevalence of sleep disturbances and to identify associated clinical and psychosocial factors in this patient population.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA total of 231 breast cancer patients receiving chemotherapy were evaluated. Data on demographic characteristics, menopausal symptoms (Menopause Rating Scale, MRS), anxiety and depression (Hospital Anxiety and Depression Scale, HAD-A and HAD-D), health-related quality of life (Nottingham Health Profile, NHP), and sleep quality (Pittsburgh Sleep Quality Index, PSQI) were collected. Correlation analyses were performed using Pearson coefficients. Logistic regression analyses were conducted to identify predictors of sleep disturbance, defined as a PSQI score\u0026thinsp;\u0026ge;\u0026thinsp;5.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eThe prevalence of sleep disturbance was 64.5%, with a median PSQI score of 6 (range, 0\u0026ndash;19). PSQI scores were moderately correlated with MRS (r\u0026thinsp;=\u0026thinsp;0.432) and NHP sleep scores (r\u0026thinsp;=\u0026thinsp;0.461) (both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and weakly but significantly correlated with HAD-A, HAD-D, and multiple NHP subdomains including social isolation and emotional reaction (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In univariate logistic regression analyses, higher total MRS, HAD-A, NHP social, emotional, sleep, and part 2 scores, as well as a history of psychiatric consultation, were significant predictors of sleep disturbance. However, in multivariate analysis, only the NHP social score remained an independent predictor (OR\u0026thinsp;=\u0026thinsp;1.02, 95% CI: 1.00\u0026ndash;1.04, p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eSleep disturbance is common among breast cancer patients undergoing chemotherapy and appears to be more strongly associated with psychosocial dimensions, particularly social isolation, than with traditional biomedical variables. These findings underscore the importance of incorporating psychosocial assessments and interventions into the supportive care of this population to potentially mitigate sleep-related morbidity.\u003c/p\u003e","manuscriptTitle":"Sleep Disturbance in Breast Cancer Under Chemotherapy: A Multifactorial Analysis Emphasizing Psychosocial Dimensions","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 10:33:49","doi":"10.21203/rs.3.rs-7278096/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2d3d5dc0-0dbe-4f97-8939-b8ce83144b00","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T08:12:22+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-13 10:33:49","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7278096","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7278096","identity":"rs-7278096","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}