What is Insomnia?
A good night’s sleep is vital for our health yet cancer treatments can affect our ability to sleep soundly. Up to half of all cancer patients experience insomnia: the inability to fall asleep and stay asleep. This can go on for months or even years.
Signs you are experiencing insomnia:
- Do you wake up groggy and sluggish, and find it hard to start your day?
- After waking up in the morning, could you fall back asleep a couple of hours later?
- Are you unable to function without caffeine before noon?
- If you didn’t set an alarm clock, would you sleep past that time?
There’s a common misconception that chronic insomnia is obvious: you lay awake for hours unable to fall asleep. However, the signs of poor sleep can be insidious and subtle. You may not be aware of your disturbed sleep patterns, but you feel the effects the next day.
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What causes cancer-related insomnia?
While many patients with cancer struggle with the symptoms of insomnia, it’s not always related directly to cancer treatment. Understanding the internal and external factors that can cause poor sleep is the first step in restoring balance to sleep patterns. Some of the main culprits are:
1. Psychological Stressors
The most common triggers of insomnia are worry and anxiety. After a cancer diagnosis, it’s normal that the mind races and it can be hard to turn it off.
2. Treatment and Treatment-Related Symptoms
Some chemotherapy protocols and cancer drugs can act as stimulants. Doctors, nurses, and pharmacists are familiar with these side effects, so ask if your insomnia could be related to your treatments.
If you are in pain before you fall asleep, falling asleep is more difficult. Discomfort and nausea from treatments can also impact sleep quality.
4. Tobacco, Alcohol, and Caffeine Intake
Nicotine in tobacco is a stimulant and can cause very light sleep. While the impacts may not be obvious, caffeine and alcohol impact circadian rhythms. You may fall asleep fine, then experience a sleep disruption later in the night.
- Alcohol is a sedative that can cause sleep cycles to be disrupted and suppress deep REM (Rapid Eye Movement) sleep. REM sleep is critical restorative sleep.
- Caffeine overrides the body’s urge to sleep and tricks you into feeling alert and awake. Caffeine has a half-life of 5-7 hours. So, having coffee with dinner at 7 pm means 50% of the caffeine will be in your body until 12 am, and the remaining half even longer.
Possible sources of caffeine
Here are some expected (and unexpected) sources of caffeine that can affect sleep:
- Coffee, black tea, and green tea
- Colas and diet colas
- Other soft drinks like Mountain Dew, Barq’s Root Beer, and Sunkist
- Decaffeinated coffee and tea (most herbal teas contain no caffeine)
- Chocolate, including chocolate ice cream (the darker the chocolate, the more caffeine)
- Mocha, or coffee-flavored ice cream or candy
- Weight loss pills: they rely on caffeine to speed up metabolism
- Any beverage marketed as an energy drink like Red Bull; even Vitamin Water Energy has caffeine
- Any product marketed as an “Energy Food” including Jolt gum, Foosh, Penguin mints, Morning Spark instant oatmeal
Sometimes creating awareness around your caffeine intake makes a big difference in minimizing nighttime awakenings.
How is insomnia diagnosed?
If you’re struggling to fall asleep and stay asleep, or notice excessive daytime fatigue that you can’t shake off, talk to your cancer care team. Cancer-related fatigue isn’t always a sign of insomnia. While the effects replicate insomnia symptoms, cancer-related fatigue can be related to an underlying medical condition. It is important to talk to your health care team to rule out other issues.
When health professionals diagnose insomnia, they evaluate several factors. They may ask about your sleep history and sleep routines. They might ask about your environment to determine if any external factors are causing sleep restriction. You’ll likely answer questions within the context of cancer and about your general lifestyle.
When diagnosing insomnia, you may be asked to track data about your lifestyle and sleep hygiene. For example, what food and drinks you consume, alcohol and tobacco use, and whether you get regular exercise.
Using a sleep diary or a fitness tracker that captures your hours of sleep and sleep cycle information will help health professionals with the diagnostic process.
Do certain cancers increase the risk of insomnia?
There are currently no studies showing a direct link between specific types of cancer and the development of chronic insomnia.
According to the National Cancer Institute, some studies indicate the potential for higher risk of insomnia in breast cancer patients and ovarian cancer patients. This increase could be related to the effects of cancer treatments as they relate to hormonal regulation (an increase in hot flashes, etc.). This increase could also be related to the fact that there are more studies about insomnia affecting women with breast cancer than other cancers.
Other studies show a potential link between the cancer stage and insomnia. It’s more common to see insomnia in patients with advanced cancer.
Why is addressing insomnia so important?
Insomnia takes a toll on our already-compromised immune systems. Evidence suggests that getting less than 8 hours of sleep a night can more than double the risk of cancer over time. And sleeping only 4 hours a night can reduce our natural killer cell counts by 70%. Lack of sleep can also create inflammation throughout the body, one of the root causes of cancer.
On the flip side, 8 hours of restful sleep can help promote recovery and enable us to recharge physically and mentally.
- Sleep helps tissues repair themselves, and organs to clear out toxins
- Good sleep enables us to remain composed in stressful situations (recovering from cancer is a very stressful situation)
- Sleep helps our brains function better, warding off “chemo fog”
- In deep restorative sleep, blood pressure drops, breathing becomes slower, muscles are relaxed, creating an environment for growth and repair
- Better sleep means a better quality of life
The inability to get a good night’s sleep can leave us feeling drained, exhausted, and overwhelmed, especially during cancer treatment and in its aftermath. Insomnia can make it difficult to engage with family and friends, attend our medical appointments, and take care of ourselves throughout the day.
Steps to overcome Insomnia
The reasons for our insomnia can change over time. And if you struggle with insomnia, no single activity is likely to address the problem. You will need to find the combination that works for you best.
Mend Together’s founder Lisa Lefebvre says, “For me, it’s going to a hot yoga class as often as I can, installing light dimmers throughout my house, making sure I sleep in a cool room, putting blue-light blockers on all my screens, and everyday use of a sleep supplement (not just on nights I can’t sleep).”
Everyday tips for better sleep
1. Create a regular sleep schedule
Go to bed and wake up at the same time every day to establish a natural body rhythm. Our bedtimes should be early enough to allow 8-9 hours sleep a night. Data shows that having regular sleep/wake hours is the single most effective way to improve sleep.
2. Use light to simulate sleep time
Install dimmers switches in your home. If you can’t afford to do it in every room, at least attend to your bathroom, hallway, and bedroom. And use them. Nature dims the world for bedtime with a sunset. Emulate this in your home. Many of us don’t realize how jarring bright overhead lights can be to a body that needs to ready itself for sleep. “I find that even a temporary exposure to bright light before bedtime can interrupt my ability to fall asleep,” says Lisa.
3. Replace blue light with warm tones
Also, change lightbulbs in sleeping areas to warm-toned models. Most energy-saving LED light bulbs emit a cooler, blue light that interferes with our production of melatonin – the hormone that tells us it’s time for bed. Instead, install bulbs appropriate for PM use.
4. Put away electronic devices
Electronic devices also emit blue light. Using your smartphone for extended periods of time, especially before bed, can disrupt your sleep patterns. Avoid using electronics in the hour before bed.
5. Turn down the temperature
Set your evening bedroom temperature to 60-67 degrees. Sleeping in a cool room helps us stay asleep. Even healthy individuals experience a dip in body temperature throughout the night, making it easy to overheat. If you experience hot flashes, having cooler surroundings can help. If your scalp is exposed, consider wearing a comfortable cap to bed.
6. Change your surroundings
Change your bedroom scenery. If we’ve been bedridden for a while but are now in recovery mode, our bodies may still associate our surroundings with the context of cancer. I found it helpful to repaint my bedroom walls, rotate the artwork I had been staring at for months, and change up my bedding and pajamas. Getting distance from those visual triggers created a more positive mood which translated into more restful sleep. This is a great task to share with loved ones who want to help you but don’t know how.
Tips for the waking hours
Better sleep habits start during the waking hours. Here are a few lifestyle changes and habits to consider to minimize sleep disturbances and overcome insomnia.
1. Cut caffeine entirely
Drastic times call for drastic measures. To truly understand the impacts of caffeine on your lack of sleep, try cutting caffeine entirely. In other words, don’t consume any of the caffeinated foods or beverages listed above. You may experience daytime fatigue initially, but the withdrawal symptoms will level out over time.
2. Move your body
Exercise every day, even if it’s a 15-minute walk. Exercise is nature’s way of wearing us out – in a good way. If you’ve just finished treatments, it’s hard to imagine exercising again. Get your family and friends involved: the next time someone asks what they can do to help, ask them to exercise with you. Plus, getting regular exposure to the daytime sun also contributes to sleep at night.
3. Try yoga
Try a hot yoga class. Lisa attributes a large part of her recovery and ongoing health to her hot yoga practice. It hits everything in one 90-minute session including strength-building, flexibility, cardio, meditation, and detoxification. And because of the heat, it burns 600-800 calories in one session, which creates fatigue at bedtime and promotes deep sleep.
4. Cut alcohol and tobacco
Avoid smoking and drinking. This may be easier said than done, but with a chronic sleep problem, it might be time to take a hard look at these sleep-destroying habits. At the very least, try not to smoke or drink after dinnertime.
5. Nourish your body
Be like Goldilocks. To sleep soundly, our stomachs want to be not too hungry, and not too full, just the right amount of satisfaction.
Daily sleep habits for bedtime
1. Go to bed pain-free
Don’t grin and bear it through cancer pain; take your sleep medicine. For Lisa, it’s taking two Tylenol about an hour before bed if her pain is acute that day. Other things you can do: take prescription pain medications on time or use special pillows to take pressure off sensitive points on our bodies. The bottom line is that we sleep better and our bodies recover faster if we’re not in pain.
2. Unplug and unwind
It’s already been said, but it’s worth highlighting again. Avoid electronic devices several hours before bedtime. Computer, phone, and tablet LED screens are all stimulants because they emit blue light, which is only naturally emitted by the sun in the middle of the day. As a result, blue light tricks your body into thinking it’s daytime. If you must use your device, download a blue light blocker here and you can participate in a short sleep study run by Dr. Steven Lockley of Harvard Medical School. This will give you data on your sleep patterns to help you self-assess.
3. Minimize fluid intake before bed
Avoid drinking fluids after 8pm, especially for those of us who tend to wake up in the middle of the night to use the restroom. A recent Ivy League study found that carbonated beverages irritate bladders and can cause us to wake up more often in the middle of the night.
4. Take a warm bath or shower
Take a pre-bed shower or bath. Water is a natural relaxant and temperature-neutralizing agent. To sleep soundly, our internal body temperature needs to drop 2-3 degrees, as if we were sleeping in nature. A shower or bath dissipates heat from the surface of our skin, helping cool our body’s core for sleep.
5. Avoid sleep aids if possible
Avoid taking a prescription sleep aid. Sleep aids like Ambien can knock us out for a kind of fragmented sleep but block full restorative deep sleep. That means our bodies can’t go into full repair mode, which in turn slows down the healing process. Another downside to prescription sleep aids: they are highly addictive. If you absolutely must take one, speak to your health care team about how to use it appropriately to avoid addition.
6. Try a natural sleep aid
Try a natural sleep aid instead. Insider tip: sleep supplements work best if you take them every evening because their goal is to balance your body’s biochemistry, which takes time.
7. Keep a journal
Journal your day. Many people with cancer struggle with overwhelming thoughts. Too much unproductive mind chatter can keep us awake. By recording the events of our day, we process anxious moments and empty our minds before we close our eyes. Try not to journal in bed. Find a comfortable chair or other corner of your home that can be specifically for writing to create a physical separation between journaling space and sleep space. Learn more about our free journal here.
8. Try a homeopathic spray
Although there is virtually no scientific literature that demonstrates homeopathy works, Lisa has found Sprayology’s Stress Relief and Sleep Ease products to be unexpectedly helpful.
9. Try aromatherapy
Lavender is one essential oil highly associated with sleep. Find one you like and use it regularly before bedtime to create a ritual and scent that your body associates with sleep.
10. Use earplugs
Use earplugs to block out unwanted noise in your house or neighborhood. You can get earplugs at any drug store. Many don’t work well so try a few types, including the silicone version. Insider tip: If you use foam earplugs, one road-warrior trick is to wet them first so they create an extra tight seal when they expand.
11. Block out light
Close curtains to shut out street lamps or other artificial stimuli. Blackout curtains are a smart investment to help you fall and stay asleep. Or try a sleep mask.
12. Read and relax
Read before bed. This helps reorient the mind away from worries and stimulates the imagination. Reading is the ultimate relaxation therapy. Avoid reading on topics like work or health which may trigger stress.
13. Practice mindfulness
Listen to sleep meditation tapes. Belleruth Naparstek is a psychotherapist and social worker whose Health Journeys meditation recordings are well known and respected amongst the oncology and psychotherapist communities. You can use this in combination with muscle relaxation techniques to help prevent sleepless nights.
- Don’t lie in bed awake. If you can’t fall asleep after 30 minutes, get up and try a relaxing activity until you feel sleepy. Read (remember no screens), or take a shower if you haven’t already.
- Seek cognitive behavioral therapy. See a cognitive-behavioral health therapist with expertise in sleep disorders and treatment for insomnia. Search for a CBTI therapist in your area or check out our listing of options in our test markets.
- Seek out an EMDR therapist who can help process any underlying anxieties. EMDR therapists use a unique combination of talk therapy and physical stimulation. We’re big fans.
- Read Why We Sleep for further tips. We love this New York Times bestseller. It’s an interesting read, full of whys, tips and tricks.
How can friends, family, and colleagues help?
Sleep may seem like a personal issue, but there are many things we can do to help our loved ones experiencing cancer-related insomnia. Here are some of the best ways to offer support:
- Do you sleep with a cancer patient and snore? See your doctor and get the condition addressed. It’s likely affecting the health of both you and your companion.
- Agree to sleep in a cooler, darker room even if you prefer warmer, sunnier rooms.
- Arrange for an electrician to install dimmers throughout your house. (Lisa has one on every switch and finds it makes a big difference).
- Attend a Bikram yoga class; engage in weekly walks with your cancer friend.
- Give a gift of homeopathic sprays, aromatherapy or other sleep aids.
- Install low blue light bulbs in bedroom, bathroom and hallway fixtures.
- Bring the person who can’t sleep a cup of chamomile tea 30 minutes before their bedtime.
- Draw a bath for your family member around the same time.
Dealing with cancer and sleep problems
Sleep is an important aspect of the recovery journey. Use these tips and products above to help you get better rest. Don’t hesitate to reach out to your healthcare team for additional support.
If you or someone you love is navigating cancer insomnia, you can create a free Mend Together account for additional support.
Errol J. Phillip has a PhD in Clinical Psychology from Notre Dame and is a former Clinical Research Psycho-Oncology Fellow at Memorial Sloan Kettering Cancer Center.
Information provided here is not a substitute for medical advice. Please consult your healthcare team for advice tailored to your personal diagnosis and treatment.