Chemotherapy and radiation saved Timothy Moravits’s life. But it was the dedicated intervention of sleep specialists that gave him the kind of life he’d always wanted to live. “I’m peppier, less grumpy, more alert and more focused,” says Moravits, 60 (see “Getting Back in the Boat.")
Restorative sleep, the kind during which one sleeps soundly for seven or eight hours and wakes up refreshed, is a rare and precious commodity for many people with cancer. Both cancer and many of its treatments increase inflammatory chemicals that disrupt the body’s natural sleep/wake cycle, or circadian rhythm.
“Up to 60% of patients with cancer will have a sleep complaint, and these sometimes last five or 10 years into survivorship,” says Diwakar Balachandran, MD, medical director of the sleep center at MD Anderson Cancer Center in Houston, where Moravits was treated.
Insomnia is the most common issue. It’s defined as trouble falling asleep or staying asleep—resulting in daytime discomfort (fatigue, irritability, trouble concentrating, anxiety)—that occurs at least three times a week for at least three months. “People expect side effects like losing your hair or nausea but not sleep problems,” says Rina Fox, PhD, MPH, a clinical health psychologist at Northwestern University Feinberg School of Medicine in Chicago. “I often encounter people who have finished treatment and were ready to go back to normal, but normal isn’t there—because of sleep.”
It’s a vicious cycle. Going in for chemo, you don’t sleep well the night before, and then you find yourself napping during the day, so you have trouble getting back to sleep that night. Now you’re tired during the day, perhaps apathetic and a little depressed, so it’s not easy to do things that help you recover mental and physical health faster, such as eating well, seeing friends and taking walks. A temporary sleep problem becomes chronic. That may impair how you feel, recover and even respond to treatment. In one study of people with metastatic colorectal cancer, those who didn’t have a regular circadian rhythm were five times more likely to die within five years. Says Balachandran, “Sleep disturbances may be carcinogenic.”
Sleeping pills are not the answer. “If you talk to your oncologist about sleep problems, you will likely get a prescription for Ambien,” says Balachandran. These hypnotic sedatives are not effective long-term solutions, studies show, and they contribute to falls and driving accidents and may increase cancer risk.
“I don’t like the effect they have on me,” says Shabana Mir, a professor of anthropology in Chicago who was treated for breast cancer twice, in 2009 and again when it recurred in 2015. “They don’t stabilize my sleep, not even on a temporary basis.” Says Sonia Ancoli-Israel, PhD, an emeritus professor of psychiatry and medicine at the University of California, San Diego, who’s been studying sleep and cancer for 25 years, “No supplements, including melatonin, work effectively for insomnia.”
The good news: Effective, noninvasive, safe, affordable nondrug ways to protect your sleep before, during and after treatment are available.
The Circadian Dilemma—and a Bright Solution
Our bodies thrive when we go to sleep and wake up at about the same time each day. Disturbing this circadian rhythm is a key way that cancer and its treatments contribute to fatigue, insomnia and depression.
Chemotherapy is a common trigger. In a series of studies on women with Stage I, II or III breast cancer, Ancoli-Israel showed that circadian rhythms were impaired as soon as the first week of chemo and progressively worsened as treatment proceeded. A year later, the women’s sleep patterns had partially recovered but were still not as healthy as those of people without cancer.
Fortunately, there’s a proven way to protect one’s circadian rhythm. It’s called bright light therapy. This approach uses small boxes that emit light that mimics bright sunlight. In a typical study, subjects spend 30 minutes each morning upon awaking sitting in front of the light box, often for 30 days or more. When bright light enters our eyes, it sends signals to the brain’s “master clock,” the suprachiasmatic nucleus, which controls the sleep/wake cycle. In Ancoli-Israel’s studies, bright light therapy prevents circadian rhythm disruptions, reduces fatigue and prevents deterioration in quality of life, including the onset of depression. “Many cancer patients stop their treatments because the fatigue is so bad,” she says, “but there’s very little out there that can help. Bright light can.”
Bright light therapy works well for people in treatment for many different cancers. In one study published in Cancer Medicine, for example, patients with multiple myeloma undergoing an autologous bone marrow stem cell transplant were bathed in bright light from a special standing lamp each morning in their hospital rooms. Depression rates dropped from 68% to 42%.
“I believe everyone undergoing chemotherapy should use bright light therapy for 30 minutes every morning through every cycle,” says Ancoli-Israel. “For survivors, continue until you feel better.” She adds, “It’s non-UV light, so there’s no worry about harmful radiation, although you should always tell your medical team what you are doing.”
In her studies, researchers use a commercially available product; reliable ones are available for as little as $100. If you don’t have one, sit next to a sunny window each morning. If you’re up to it and it’s a nice sunny day, sit outside or take a walk in the morning. Just don’t wear sunglasses for that half hour, so the light gets to your eyes.
The Insomnia Cure
While bright light therapy is effective at resetting one’s circadian rhythm, countering fatigue and reducing depression, it’s only part of the solution. To fully tackle insomnia, the best treatment, according to the American College of Physicians and other medical groups, is cognitive behavioral therapy for insomnia (CBT-I). One analysis of people with cancer, published in Sleep Medicine Reviews, looked at eight randomized clinical trials. CBT-I significantly increased the time spent in bed sleeping (versus tossing and turning). People spent less time falling asleep and less time waking up and staying awake. Self-reported insomnia scores decreased substantially. Six months later, the sleep benefits were still evident.
CBT-I works by helping you make changes in sleep habits that sound easy but are really hard to achieve. These include:
- limiting daytime naps
- avoiding stimulants, such as coffee, in the afternoon and avoiding alcohol in the evening
- going to sleep only when you feel sleepy at night yet getting up at the same time each morning
- not spending too much time in bed (seven hours of sleep out of eight hours in bed is better than seven hours of sleep out of nine hours in bed)
- establishing a relaxing pre-bedtime ritual, such as reading
- making sure your bedroom is cool, dark and free of distractions such as cellphones, tablets and TV.
“It sounds easy to take your television out of your bedroom, but maybe when you’re going through cancer treatment the TV in your bedroom gives you a lot of comfort,” says Northwestern’s Fox. “Maybe you Skype on the TV with your mom.” Working with a CBT-I therapist, she explains, “can help you find ways in which these changes will work best for you. It’s the gold standard for treating insomnia.”
In a typical scenario, you meet once a week, for about six to eight weeks, with a CBT-I trained therapist. More affordable options such as group sessions or online programs/apps (SHUTi, Sleepio, CBT-i Coach) can also help. “CBT-I reteaches you how to sleep,” says Ancoli-Israel. “It targets poor habits and helps you break them.”
“It’s made a big difference,” says cancer survivor Mir, who enrolled in a CBT-I program overseen by Fox at Northwestern’s Center for Circadian and Sleep Medicine in the summer of 2018. Her treatment ended in 2015 (she’s in remission), but the insomnia lingered. “In the beginning, the CBT-I was rough, since you have to practice waking up at a certain time, no matter how much sleep you’ve gotten. The idea is to build up your ‘sleep hunger.’” But within a few weeks, after working on several habit changes, Mir was sleeping longer and more soundly and has maintained her good sleep habits ever since. “It’s so nice to be able to wake up and feel rested,” she says.
How to Get Sleep Help
Cancer and its treatment can interfere with sleep in different ways. You may have pain that keeps you up at night—and if you’re taking narcotics, these can interfere with sleep too. Hormonal therapy can affect sleep as can anxiety and depression. Platinum-based chemotherapy drugs can damage nerves and contribute to restless leg syndrome, another cause of insomnia.
That’s why the first step is to discuss your symptoms with your care team. “Start with your oncologist,” says Ancoli-Israel. “If you don’t get an answer that satisfies you, ask for a referral to a sleep specialist—ideally someone who is board certified in sleep medicine.” You can improve the quality of your life, she says. “I’ve seen it happen many times.”
To learn about sleep apnea and cancer, see "Getting Back in the Boat."
To learn more about sleep and cancer, see “Sleeping Better When Living With Cancer.”