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 among many patients, according to Katherine Walsh, PhD, LICSW, an oncology social worker in private practice and a professor of social work at Westfield State University in Northampton, Massachusetts.
“Studies show about one-third of individuals treated for cancer experience anxiety that impacts their quality of life,” says Dr. Walsh. “Worrying about health, the emotional impact of your cancer on your family, financial costs of treatment, and whether your life will be shortened are all very common concerns among individuals with cancer.”
And that 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 percent of cancer patients reported sleep disturbances after diagnosis. And over 40 percent of cancer patients undergoing therapy experience insomnia, according to a study published in 2019 in Sleep Breathing Physiology and Disorders
But sleep issues and breast cancer have a particularly complex relationship. Research published in Aging in 2020 also uncovered an association between sleep apnea and developing breast cancer, finding that people genetically at risk for developing sleep apnea were more likely to develop breast cancer than people with no family history of the sleep disorder. A study published in Behavioral Sleep Medicine in 2021 assessed the sleep patterns of 460 women with breast cancer and found that almost 80 percent of the participants experienced insomnia symptoms.
And a study published in Sleep Medicine in 2019 suggested that irregular sleep patterns are also associated with breast cancer progression.
“We’ve seen in multiple epidemiological studies that there is a connection between sleep and circadian function with breast cancer risk and mortality,” says Eric Zhou, PhD, an attending 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 among women with breast cancer. “Women [in general] are more likely than men to suffer from insomnia,” he says.
There is also enough circumstantial evidence that tumor biology causes inflammation, which is a contributing factor to insomnia, notes Oxana Palesh, PhD, MPH, a professor in the department of psychiatry and director of the Palesh Cancer Survivorship Laboratory in the Massey Cancer Center at Virginia Commonwealth University in Richmond. That means 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.
Dr. Palesh and Zhou both say that people with cancer form habits to cope with exhaustion during treatment that help in the short-term, but eventually lead to insomnia. “For example, [a patient] might take a long daytime nap because she is so exhausted during radiation therapy,” says Zhou. “Once she is finished with treatment, she may continue this habit, but it can cause her to struggle to fall asleep at night consistently.”
Walsh notes that breast cancer treatment 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, which interrupt sleep,” she says.
When to Get Help
If it takes more than 30 minutes for you to fall asleep, or if you’re 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 likely have insomnia, according to Zhou. “Even if a breast cancer patient does not check off these boxes, feeling dissatisfied with the quality of their sleep, or not waking up feeling refreshed, are good reasons to consult with experts to explore what might be going on.”
Sometimes people who struggle with sleep are not even aware of it. “Other people in their life may be aware that they are not sleeping well, but do not realize the negative impact loss of sleep has on well-being,” says Walsh. She notes that if you are experiencing an increase in irritability, fatigue, a depressed mood, and anxiety during the day, it may 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 insomnia symptoms early.” The general recommendation, she explains, is symptoms that last anywhere between one to six months might resolve on their own. “But there is a scientific debate about this, and I tend to recommend that patients treat symptoms early on so they don’t take the risk of insomnia becoming chronic later on.”
Techniques That Work Best for Insomnia
Revamping your sleep hygiene (sleep habits) isn't always enough. “The American Academy of Sleep Medicine has advised against using sleep hygiene [alone], because it is ineffective on its own,” says Zhou. “Rather, sleep hygiene is one part of a multi-modal treatment, called ‘cognitive behavioral therapy for insomnia [CBTI],’ that is recommended.”
According to all three experts, CBTI is considered the gold standard of treatment for cancer-related insomnia. A meta-analysis published in Sleep Medicine Reviews in February 2021 supported CBTI as an effective mode for improving sleep quality in women with breast cancer. And in a study published in 2022 in the journal Sleep, investigators found that CBTI plus light therapy significantly helped women with breast cancer sleep better.
Zhou says CBTI’s suite of tools teaches a patient how to approach sleep differently, from both a behavioral and a cognitive perspective. And Palesh says CBTI differs from CBT for anxiety or depression because it’s a shorter course of sessions (only seven), has a stronger focus on behavior change, and is customized to help you sleep.
“CBTI can be very effective in helping with both 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 changing intrusive or negative thoughts.” It also uses relaxation techniques, like guided imagery and progressive muscle relaxation. “These treatments have been found to be even more effective than many sleep aids, although medication is sometimes used in combination with them.”
“In the short-term, medications for sleep can be valuable,” Zhou adds. “An example could be shortly after a patient is diagnosed with breast cancer. However, sleep aids are designed to be short-term solutions and not long-term fixes.” Zhou thinks it is essential that patients discuss an “exit strategy” with their doctors if they recommend a sleep aid, with the goal of transitioning 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’re tired. “I have yet to meet someone who can will themselves to sleep,” says Palesh, “so you want to get acquainted 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 struggling with insomnia.”
- Wake up at the same time every day. Set your alarm for the same time daily to help retrain your body to have a routine rhythm.
- Take breaks from 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 sleeplessness,” says Palesh. “Try again in a half an hour.”
- Be mindful about light. 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 back-lit electronic screens on TVs, mobile phones, and computers, can also make it difficult for you to fall asleep and stay asleep. Avoid blue light for a couple of hours before bed. Walsh and Palesh both recommend swapping TV and digital devices for relaxing practices like reading or listening to calming music before bed. Meanwhile, starting your day with lots of light and exercise can stimulate your brain when you wake up to help reinforce your sleep cycle, according to Palesh.
- Limit what you do in your bed. “We want to associate bed with sleep and sex only,” Palesh says. So while you read or practice relaxation exercises before bed, make sure not to do these things in your bed — no matter how relaxing they might be.
- Set a sleep-friendly eating routine. Avoid eating or drinking alcohol for two or three hours before going to bed. Also, avoid caffeine in the afternoons and evenings.
“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 eventually help you sleep.
Acupuncture can also help, but the research to back it up is still iffy. “A lot of people like it and it helps with stress reduction and pain,” says Palesh. “People swear by it, but we don't have enough good [scientific] evidence that it will help everybody.”
But all three experts are optimistic that you can break your insomnia cycle, especially with a little help from your care team. “There is a great deal that can be done,” Walsh says, “if people affected by cancer let their oncology providers help.”