Everyone diagnosed with cancer has access to a powerful tool that can help them stay strong and remain calm, all while encouraging their body’s immune system to seek out and destroy every cancer cells it finds.
The problem is many patients are completely unaware of the benefits of this therapy or, for reasons unknown, can’t get enough of it.
What is this amazing elixir? Sleep.
“We have devalued sleep for so long,” said Fred Hutchinson Cancer Center epidemiologist Amanda Phipps, PhD, MPH, who studies how lifestyle factors impact cancer risk and outcomes. “Sleep is viewed almost as a luxury, but in reality, it’s an essential human function. And there are clinical and biological consequences for patients with cancer who are not getting as much sleep as their bodies’ need.”
Sleep is so valuable to cancer patients that the National Comprehensive Cancer Network just updated their survivorship guidelines to include new recommendations for clinicians to check in with patients about their sleep.
Research shows a full third of cancer survivors experience long-term sleep disturbances, yet very few are evaluated for sleep disorders. The NCCN recommends clinicians screen cancer survivors for potential sleep disorders such as insomnia, sleep apnea, restless leg syndrome and circadian rhythm sleep-wake disorders. They also provide a number of strategies for addressing and managing these disorders so patients can get good, consistent sleep.
Cancer, Stress and Sleep
How much sleep do you need?
The American Academy of Sleep Medicine recommends adults get a minimum of seven hours of sleep a night. But whether it’s anxiety over a new cancer diagnosis or lost ZZZZs due to a long-put-off homework assignment, many of us fall short.
“We all know that feeling when we don’t get enough sleep or just get restless sleep,” Phipps said. “That feeling of fatigue, the fuzziness. Those are the short-term implications. But there are long-term impacts as well.”
Lack of sleep affects the body’s stress response as well as its inflammatory response, she said.
According to the National Institutes of Health, poor sleep disrupts the immune system at a molecular level, interfering with disease-fighting factors, including proteins called cytokines.
This can hurt the body’s ability to fend off infections, like colds, flu or COVID-19. Poor sleep has also been shown to make vaccines less effective by reducing the body’s ability to respond. And many studies throughout the years have linked poor sleep to an increased risk of heart disease, cancer, kidney disease, high blood pressure, diabetes, stroke and obesity.
Unfortunately sleep is understudied in cancer patients, Phipps said.
Not Sleeping? Tell Your Doctor!
“As soon as my head hit the pillow, my mind would just replay everything that was going on,” said Jennifer Douglas, a 45-year-old homemaker from Santa Clarita, Calif., who was diagnosed with ductal carcinoma in situ, or DCIS, in 2019. “I’d worry about biopsies, or treatment decisions I needed to make, or would worry about my kids. As soon as the lights went out, it was prime time to worry.”
Phipps totally gets it.
“Cancer patients can have a lot of anxiety as well as stress and pain and treatment side effects,” she said. “All those things can detract from their ability to get the sleep their bodies need.”
Patients going through a cancer diagnosis and treatment are also commonly on medications that can interfere with sleep, whether steroids to keep the body’s inflammation response to toxic drugs to a minimum or anti-hormones that cause insomnia.
Dennis Keim, a 70-year-old breast cancer survivor from Lincoln, Nebraska, said the drugs used during therapy definitely impacted his rest.
“My sleep has been fragmented since chemo,” he said. “At one point my doctor suggested diphenhydramine, but that was about it. I decided it wasn’t for me; it did not promote a high quality of sleep.”
Phipps acknowledged getting a good night’s sleep is easier said than done — especially for people dealing with cancer.
“It may not be realistic or doable for a patient who’s in the thick of things,” she said. “There are many reasons why a person could have trouble sleeping. And treatment for insomnia can vary based on the factors that contribute to it.”
Her advice? Have a conversation with your provider — whether an oncologist or a primary care physician — and figure out what’s causing it.
Drug doses can be adjusted, she said, as can other factors that may affect your rest.
“It’s about your environment,” Phipps said. “If you know you’re ramped up, control the things you can. Control your caffeine consumption. Don’t work out immediately before bedtime. Don’t scroll your phone before bedtime. You may not be able to control your response to steroids, but you can control aspects of your environment.”
Phipps said the goal is for somebody to bring it up — whether patient or doctor — in order to figure out effective workarounds.
“It’s not just a nuisance,” she said. “Treat a sleep challenge as important. Don’t put it at the bottom of the list.”
Testing for Sleep Apnea
One contributing factor many are unaware of is sleep apnea, an intermittent obstruction of the airway during sleep.
“Sleep apnea is perhaps the easiest problem to target,” Phipps said. “Most people aren’t diagnosed, so they don’t know they have it. They may have just been told that they snore, or snore loudly, by a partner. But there’s a clear test and a clear treatment for it.”
A sleep study and a test, administered by a doctor, are required for diagnosis. Once diagnosed, many people are prescribed a CPAP, or continuous positive airway pressure, machine which they wear to bed every night. The constant delivery of steady air pressure helps them to breathe.
“Sleep apnea is more common among men but it’s underdiagnosed in both men and women,” Phipps said. “There’s also a strong association between sleep apnea and changes in body size. We will often see it in pregnant people or people with obesity.”
And it’s not a harmless condition.
In sleep apnea, the body periodically stops breathing. When this happens, the person will sometimes awaken, gasping for breath, but will go right back to sleep and not remember it. Unfortunately, the more severe the condition gets, the longer and more frequent the breathing gaps become.
“Over time, that contributes to inflammation and sets off a cascade that we think can lead to the development of certain kinds of cancer,” Phipps said. “We’ve seen an increased risk of melanoma and kidney cancer with obstructive sleep apnea as well as associations with stroke and heart disease, increased risk of dementia and Alzheimer’s.”
How’s Your Sleep hygiene?
Keim, the breast cancer survivor from Nebraska, said he hasn’t been tested for sleep apnea but he practices good sleep hygiene, which has enabled him to get better rest.
“I have a sleep mask that’s quite good,” he said. “And try to say no to sleep aids. Sticking to the many sleep hygiene lists of recommended habits and practices seemed like a better way to go over the long run.”
Phipps agrees that medications aren’t necessarily a long-term strategy.
“There are differences of opinion, but my understanding is long-term use of sleep medications is just not recommended,” she said. “I know people will sometimes self-medicate with things like cannabis and alcohol, but with that, it’s good to remember you’re not solving the underlying problem. You’re just self-medicating.”
Douglas, the DCIS patient, said her insomnia went away as soon as she got her cancer treatment plan, then came roaring back when she began taking an anti-hormone drug.
“[It] was a beast to deal with,” she said. “I started having insomnia as soon as I started taking it.”
She talked to her oncologist about whether diphenhydramine was a good option for her or if it was contraindicated.
“He was like once in a while it’s okay, but if it’s a long-term thing we need to keep talking,” she said. “So I started exercising more. I discovered the more active I was in the morning, the more tired I was and the more I slept at night.”
Douglas also read books on sleep and tried to follow good sleep hygiene by keeping her bedroom dark, avoiding stress before bedtime and keeping a consistent routine.
All great ideas, Phipps said. In addition, she said it’s important to remember sleep has multiple dimensions.
“We often focus on sleep duration but that’s not necessarily the one that counts the most,” she said. “It’s just what we’ve studied the most. Consistency of sleep is also important. Set yourself up for success by creating a consistent sleep environment and prioritizing it. Think about making sustainable changes. Focus on your bedtime — have consistency there. Focus on your environment — improve that if you can.”
Most of all, she said, try to be patient with yourself – especially if you’re dealing with cancer.
“Be kind to yourself and set realistic goals to better set yourself up,” she said. “And definitely talk to your doctor. The sleep will come.”
This article was originally published August 17, 2023, by Fred Hutch News Service. It is republished with permission.