Sleep affects nearly every aspect of our health, including our immune system, memory, and learning. But a cancer diagnosis can cause a lot of anxiety, which is a common cause of insomnia in many patients, according to Katherine Walsh, PhD, LICSWoncology social worker in private practice and professor of social work at Westfield State University in Northampton, Massachusetts.
“Studies show about a third of people treated for cancer experience anxiety that affects their quality of life,” says Dr. Walsh. “Worrying about health, the emotional impact of your cancer on your family, the financial costs of treatment and whether your life will be shortened are all very common concerns among people with cancer.”
And this anxiety can lead to prolonged tossing and turning. Research published in the Journal of the National Comprehensive Cancer Network in 2020 found that more than 60% of cancer patients reported sleep disturbances after diagnosis. And more than 40 percent of cancer patients who undergo therapy suffer from insomnia, according to a study published in 2019 in Physiology and sleep-disordered breathing
But sleep problems and breast cancer have a particularly complex relationship. Research published in Aging in 2020 also found an association between sleep apnea and the development of breast cancer, finding that people genetically at risk of developing sleep apnea were more likely to develop breast cancer than people without a family history sleep disorder. A study published in Behavioral sleep medicine in 2021 assessed the sleep patterns of 460 women with breast cancer and found that nearly 80% of participants had symptoms of insomnia.
And one study published in sleep medicine in 2019 suggested that irregular sleep patterns are also associated with breast cancer progression.
“We have seen in several epidemiological studies that there is a link between sleep and circadian function with breast cancer risk and mortality,” says Eric Zhou, PhDattending psychologist in psychosocial oncology and palliative care at the Dana-Farber Cancer Institute at Harvard University in Boston.
According to Dr. Zhou, insomnia is the most common sleep disorder in women with breast cancer. “Women [in general] are more likely than men to suffer from insomnia,” he says.
There is also sufficient circumstantial evidence that tumor biology causes inflammation, which is a contributing factor to insomnia, notes Oxana Palesh, PhD, MPH, professor in the department of psychiatry and director of the Palesh Cancer Survivorship Laboratory at the Massey Cancer Center at Virginia Commonwealth University in Richmond. This means that the molecular mechanisms associated with and caused by cancer can cause your body’s immune and other systems to react in ways that keep you awake at night.
Both Dr. Palesh and Zhou say people with cancer develop habits to deal with exhaustion during treatment, which helps in the short term, but eventually leads to insomnia. “For instance, [a patient] might take a long nap during the day because she is so exhausted during radiation therapy,” Zhou says. “Once she’s finished treatment, she can continue this habit, but it can cause her to have trouble falling asleep at night consistently.”
Walsh notes that treating breast cancer with tamoxifen or aromatase inhibitors can be another major cause of insomnia. “[Those medications] can cause menopause-like symptoms, such as night sweats or joint pain, that interrupt sleep,” she says.
When to get help
If it takes you longer than 30 minutes to fall asleep, or if you are up for at least 30 minutes in the middle of the night tossing and turning most days of the week for at least three months, you are in pain. probably from insomnia, according to Zhou. “Even if a breast cancer patient doesn’t tick these boxes, feeling dissatisfied with the quality of her sleep or not waking up rested are good reasons to see experts to explore what might be going on.”
Sometimes people who have trouble sleeping aren’t even aware of it. “Other people in their lives may be aware that they are not sleeping well, but not realize the negative impact of sleep loss on well-being,” says Walsh. She notes that if you’re experiencing increased irritability, fatigue, depressed mood, and anxiety during the day, it might be time to get help.
“Continued sleep disruption can contribute to the development of depression,” Palesh confirms. “If people have depression or other psychological symptoms, I would say treat the insomnia symptoms early.” The general recommendation, she explains, is that symptoms that last between one and six months may go away on their own. “But there’s a scientific debate about it, and I tend to recommend that patients treat symptoms early so they don’t risk the insomnia becoming chronic later on.”
Techniques that work best for insomnia
Rearranging your sleep hygiene (sleep habits) is not always enough. “The American Academy of Sleep Medicine advised against using sleep hygiene [alone], because it is ineffective on its own,” says Zhou. “Rather, sleep hygiene is part of a multimodal treatment, called ‘cognitive-behavioral therapy for insomnia’. [CBTI]’, it is recommended.
According to the three experts, CBTI is considered the gold standard for treating cancer-related insomnia. A meta-analysis published in Opinions on sleep medicine in February 2021 supported CBTI as an effective mode to improve sleep quality in women with breast cancer. And in a study published in 2022 in the journal Sleep, researchers found that CBTI combined with light therapy significantly helped women with breast cancer sleep better.
According to Zhou, the CBTI suite of tools teaches the patient how to approach sleep differently, both behaviorally and cognitively. And Palesh says CBTI differs from CBT for anxiety or depression because it’s a shorter cycle of sessions (just seven), has a greater focus on behavior change, and is personalized to help you. to sleep.
“CBTI can be very effective in addressing treatment-related and anxiety-related sleep issues,” says Walsh. “This short-term treatment is provided by many social workers and other mental health clinicians and includes identifying and modifying intrusive or negative thoughts.” He also uses relaxation techniques, such as guided imagery and progressive muscle relaxation. “These treatments have been shown to be even more effective than many sleeping pills, although medications are sometimes used in conjunction with them.”
“In the short term, sleep medications can be invaluable,” adds Zhou. “An example might be shortly after a patient is diagnosed with breast cancer. However, sleeping pills are designed to be short-term fixes, not long-term ones. Zhou thinks it’s essential that patients discuss an “exit strategy” with their doctors if they recommend sleep aid, with the goal of switching to cognitive behavioral therapy for insomnia in the future.
6 steps you can take to help you sleep
Follow these CBTI-informed steps to help stabilize your sleep schedule:
- Go to bed when you are tired. “I haven’t met anyone who can fall asleep yet,” Palesh says, “so you want to get familiar with your body, learn to recognize when you’re feeling sleepy, and that’s when you go to bed. Don’t use the clock to tell you when to go to bed when you have insomnia.
- Wake up at the same time every day. Set your alarm at the same time every day to help your body get back into a routine rhythm.
- Take breaks while trying to sleep. “If you go to bed and can’t sleep within half an hour, get out of bed so you don’t form the association in your brain with bed and insomnia,” says Palesh. “Try again in half an hour.”
- Be aware of the light. The light can stimulate your brain and interrupt your body’s release of melatonin. Exposure to blue light, which comes from fluorescent and LED lights and backlit electronic screens on TVs, cell phones, and computers, can also keep you from falling asleep and staying asleep. Avoid blue light for a few hours before bedtime. Both Walsh and Palesh recommend replacing television and digital devices with relaxing practices like reading or listening to soothing music before bed. Meanwhile, starting your day with plenty of light and exercise can boost your brain upon waking to help strengthen your sleep cycle, according to Palesh.
- Limit what you do in bed. “We want to associate the bed with sleep and sex only,” says Palesh. So, while you read or practice relaxation exercises before bed, make sure you don’t do these things in bed, however relaxing they may be.
- Establish a sleep-friendly eating routine. Avoid eating or drinking alcohol for two or three hours before going to bed. Also, avoid caffeine in the afternoon and evening.
“These things, along with exercise and healthy eating during the day, can make a big difference,” Walsh says.
Palesh also says yoga can help people sleep better. But don’t be discouraged, yoga takes time to work. “It’s not like taking an Ambien,” she says. Stick with it anyway because, she adds, the breathing aspect of it will help regulate your system and possibly help you sleep.
Acupuncture may also help, but research to support it is still uncertain. “A lot of people love it and it helps reduce stress and pain,” says Palesh. “People swear by it, but we don’t have enough good [scientific] proof that it will help everyone.
But all three experts are optimistic that you can break your cycle of insomnia, especially with a little help from your healthcare team. “There’s a lot to be done,” says Walsh, “if people affected by cancer let their oncology providers help them.”