More than 80% of children diagnosed with a malignancy now survive five years, with most living well into
adulthood. This has resulted in a growing population of childhood cancer survivors, estimated to approach half
a million by 2020. Unfortunately, curative treatments result in toxicities that leave many survivors with a
substantial burden of adverse physical and mental health outcomes. Morbidities commonly observed after
childhood cancer treatment include neurocognitive impairment in 40-50% of survivors, emotional distress, and
cardiovascular disease. These late effects are often comorbid and may interact to synergistically contribute to
adverse health outcomes. Symptoms of insomnia, reported by approximately 30-45% of adult survivors of
childhood cancer, are believed to be a key player in this dynamic. We have demonstrated that insomnia is
associated with neurocognitive impairment in adult survivors of childhood cancer and that reduction in insomnia
is associated with improved cognitive performance. In the general population, insomnia is also associated with
increased cardiovascular symptoms, including a 45% increased risk of developing or dying from cardiovascular
disease. We hypothesize that by treating insomnia, improvements will be observed in neurocognitive function,
emotional distress, and biomarkers of cardiovascular risk. Cognitive Behavioral Therapy for Insomnia (CBTi) is
an established non-pharmacologic treatment that focuses on addressing problematic thoughts and behaviors
related to insomnia. However, limited access to and availability of health care professionals trained to deliver
CBTi has led to development of internet-based CBTi, which has been found effective in treating insomnia and
comorbid psychological and fatigue symptoms in the general population and in survivors of adult onset cancers.
We are proposing to conduct a randomized clinical trial to evaluate the efficacy of an internet-based CBTi
intervention (SHUTi) on insomnia in adult survivors of childhood cancer. Importantly, while SHUTi has been
shown to be efficacious in other populations, symptoms of insomnia in adult survivors of childhood
cancer may have persisted for several decades and often co-occur with other treatment-related late
effects. Therefore, we propose to examine the direct impact of SHUTi on improving insomnia, and the mediating
effect of improved insomnia on neurocognitive functioning. We also will examine the contribution of changes in
emotional distress and biomarkers of cardiovascular health following treatment for insomnia to survivor quality
of life. We will recruit 352 survivors with comorbid insomnia and neurocognitive problems from the Childhood
Cancer Survivor Study (CCSS). Positive results from this study cohort and our use of an internet-based
intervention are likely to generalize and be scalable to the large and geographically diverse population of
childhood cancer survivors with chronic health conditions.
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