The Sleep-Cancer Connection: What the Science Says

Prevalence of Insomnia in Cancer Patients

I have cancer and now I can’t sleep? Am I alone in this struggle?

Insomnia is the most common sleep disorder with estimates suggesting 10% of insomnia patients meeting criteria for  insomnia disorder and 20%  endorsing occasional insomnia symptoms (Morin & Karin, 2022).  A recent metanalysis suggests that this value is much higher in cancer patients with approximately 60% of cancer patients and survivorsreporting sleep disturbance (Al Maqbali et al., 2022).

A another way to think of this is sleep issues are 3x more likely In cancer patients or 6 of 10 cancer patients and surviors reports clinically significant sleep disturbance.

The Course of Insomnia in Cancer Patients

What can I expect about my sleep during my cancer journey?  Are there certain risk factors for the development of insomnia?

This is a very complicated question and depends on lots of different factors.  I find it helpful to give the short answer and a more nuanced long answer:

Short Answer:

For many, symptoms often peak following initial diagnosis as patients are confronted with the realities of cancer diagnosis and treatment and the implications on their life.  Just as we see a spike in anxiety at this point, sleep follows.

For some, sleep issues may worsen during treatment.  For example, 40% of individuals report moderate-severe insomnia symptoms after first round ochemotherapy (Palesh et al., 2010).

Although there is a general trend for improvement, for some insomnia can become a chronic problem.

Long Answer:

One of the best ways to understand sleep throughout ones cancer journey is to use Spielman’s 3P Model of Insomnia. 

1. Predisposing Factors: Vulnerabilities

These are your baseline vulnerabilities that make you more likely to develop insomnia, even during periods of low stress.  Similar to insomnia in the general population, general risk factors for insomnia cancer patients include:

• Older individuals

• Female sex

• Those who may have an anxiety prone personality or tendency to ruminate

• Family or personal history of insomnia and/or anxiety/dep

• Endocrine modification of circadian rhythms

• Irregular exposure to light

• Current psychiatric disorders especially anxiety and depression

2. Precipitating Factors: The Trigger

These are the acute life events or stressors that tip you over the edge and trigger the initial episode of "acute" insomnia.  In the world of cancer treatment these include cancer specific factors including:

• Worry, anxiety and distress related to cancer diagnosis or progression (e.g., death anxiety)

• Treatment related factors:

  • Radiation therapy or homone therpay with side effects that disrupt circadian rhythyms

  • Chemotherapy including nauea or vomiting, fatigue

  • Other meds (steroids, opiates, anti-hormonal treatments in breast cancers)

• Cancer-related factors. For example, insomnia in adrenal cancer is primarily driven by tumor production of cortisol and adrenaline

• Cancer symptoms including pain, cancer related fatigue, hot flashes and vasomotor symptoms, pruitis

• Surgery

• Hospitalization

3. Perpetuating Factors: The Maintainer

These are the maladaptive behaviors and cognitive changes you adopt in an attempt to fix the sleep problem, but which actually make it worse and turn it into chronic insomnia.

• Maladaptive behaviors and beliefs that patients use to cope with sleep difficulties (E.g., extend time in bed, long naps, irregular sleep schedule, inactivity)

• Worries about sleeplessness and daytime consequences of poor sleep may delay sleep onset and cause frequent awakening

• Feedback loops extended time in bed and insomnia, depression and fatigue

• Problems during the night (e.g., increased need to urinate, hot flashes)

Implications of Insomnia and Cancer

How might insomnia impact me on my cancer journey?

Insomnia influences on the immune system, neuroendocrinological function, cognitive function, general well-being and quality of life.  In cancer patients’ insomnia has been associated with increased risk of mental and physical health problems.  Specifically, insomnia is associated with higher rates of irritability, anxiety and depression and greater disability and mortality.  These implications are seen into survivorship (Strollo et al., 2020).

Are you saying that my sleep issues are making my cancer worse?

Not so fast! It is unclear.

In many ways it is hard to determine if the chicken or the egg comes first.  That is to say, do sleep disturbances contribute to cancer development/progression, or is cancer development/progression contributing to sleep issues.

Some studies suggest that chronic sleep issues may negative impact one’s immune system on a molecular level (e.g.Lanza et al., 2024). However, this is a relatively new area and clinical implications remain unclear.

What we do know is that poor sleep exacerbates side effects like pain, nausea and fatigue which may lead to impaired treatment tolerability. This can have profound implications on one’s cancer course.

Clinical Implications

I know my sleep problems aren’t helping my cancer course, what can I do?

National Cancer Center Network Guidelines and European Society of Medical Oncology Guidelines emphasize the importance of adequately assessing and treating insomnia.

Cognitive Behavioral Therapy for Insomnia (CBT-I) for Cancer Patients

The gold –standard treatment for insomnia in cancer patients is Cognitive Behavioral Therapy – Insomnia (CBT-I). The multi-component intervention focuses on sleep restriction, stimulus control, sleep hygiene, cognitive restriction and relaxation training.  A recent meta-analysis indicates CBT-I is associated with statistically and clinically significant improvements in subjective sleep outcomes in patients with cancer. Secondary benefits reveal improvements in mood, fatigue, and overall quality of life (Garland et al., 2014).  It can be effectively delivered in multiple formats including virtually and in groups.

We offer this type of treatment at Fleagle Psychology.  Click here to learn more.

Medications

Some patients also require medication management. There, unfortunately, are no perfect sleep aids.  The medication prescribed generally depends on other symptoms a patient might be managing. Benzodiazepines (e.g., lorazepam), anti-depressants (e.g., trazadone, amitriptyline, mirtazapine), or anti-psychotics (e.g., Seroquel, Zyprexa or Haldol) (e.g., Pinucci et al., 2023).

If you have questions regarding sleeping medications , I highly recommend you consult with your oncologist.  Please note sleep aids due not interfere with one’s ability to complete CBT-I.