Sleep Routine During Cancer Treatment

Sleep is the side effect people apologize for raising. It sounds minor next to a tumor. It is not minor, it is extremely common, and it has a real treatment that most people are never offered.

The National Cancer Institute estimates that one-third to one-half of people with cancer have sleep disturbances. That is not a personal failing or a sign of weak nerves. It is a predictable part of treatment, and it responds to being taken seriously.

Insomnia during cancer is rarely one thing. NCI groups the causes into physical changes from the cancer or surgery, side effects of drugs and treatments, symptoms such as pain and nausea, the hospital environment, and the anxiety that comes with the diagnosis itself.

Before changing your bedtime routine, spend three nights noticing which of these is yours. Someone woken at 2 a.m. by pain needs better pain control, not a darker room. Someone lying awake with a racing mind needs something different again.

Write down what wakes you and what time. That log is more useful at an appointment than any description of feeling tired.

Several drugs used routinely in cancer care disturb sleep, and NCI names them.

Corticosteroids are the biggest one. Steroids are given alongside many chemotherapy regimens, often to prevent nausea or allergic reactions, and sustained use is listed as a cause of insomnia. If your worst nights land on the same days of every cycle, this is the first suspect.

NCI also names sympathomimetics used for breathlessness, neuroleptics used for nausea and vomiting, and some vitamins and dietary supplements.

Ask two questions about any of these: does the dose have to be at that hour, and is there an alternative. Timing is often adjustable when someone asks.

Cognitive behavioral therapy for insomnia is a short structured program, usually a handful of sessions. NCI's professional guidance is clear that when cancer survivors have sleep-wake disturbances, cognitive behavioral counseling should be the first consideration for management. The National Heart, Lung, and Blood Institute calls it the first treatment option for long-term insomnia and says it can be very effective.

That is a strong recommendation, and it puts therapy ahead of pills rather than after them.

Five things happen in CBT-I:

• Stimulus control. You use the bed only for sleep, so your brain relearns that bed means sleep rather than lying awake worrying.
• Sleep restriction. You are given a set time to spend in bed, often less than you currently spend. Sleep becomes more solid before it becomes longer.
• Cognitive work. You address the anxiety about not sleeping, which is often what keeps you awake.
• Relaxation training. Breathing and muscle relaxation methods, taught as part of the package.
• Sleep education. The habits below, explained rather than handed over as a list.

Ask your oncology team, a psycho-oncology service, or a palliative care team for a referral. Many programs are delivered online or by phone.

These are NCI's own sleep hygiene points. They work best as part of a program, not instead of one.

• Keep the same sleep and wake times, including weekends. Regularity is what anchors the body clock.
• Keep the room quiet, dark, and at a comfortable temperature.
• Do not watch television or work in the bedroom. This is stimulus control in everyday form.
• Get regular exercise, but not within 3 hours of bedtime.
• Have a high-protein snack about 2 hours before bed, such as milk or turkey.
• Avoid heavy, spicy, or sugary food before bed.
• Skip alcohol and smoking in the evening. Alcohol makes people fall asleep faster and sleep worse.
• Cut foods and drinks with caffeine, and look at your afternoon habits closely.
• Drink more fluid during the day and less right before bed, so you are not up at 3 a.m.

You will find conflicting advice here, and it is worth knowing why.

NCI's sleep guidance says to avoid naps, because daytime sleep reduces the pressure that helps you fall asleep at night. NCI's fatigue guidance says that if you are tired, take short naps of less than one hour during the day, and warns against sleeping so much in daytime that night sleep suffers.

Both are right for different people. If your main problem is exhaustion, a short early-afternoon nap helps. If your main problem is lying awake at midnight, naps are working against you. Pick the one that matches your bigger problem, and keep any nap short and early.

Breathing exercises and progressive muscle relaxation are genuinely useful for winding down. It is worth being clear about their limits for insomnia itself.

NCCIH reports that research on relaxation techniques for insomnia is insufficient, notes that the American College of Physicians recommends cognitive behavioral therapy as the initial treatment, and states that relaxation approaches alone do not seem especially promising for sleep.

So use them, but use them inside a plan rather than as the plan.

NCI says sleep medicines may be used for a short time when other approaches have not worked. Short is the operative word, and there are specific cautions.

NHLBI notes that benzodiazepines can cause dizziness, confusion, and muscle weakness, and are habit-forming. Several classes of sleep medicine carry rare side effects that include doing things while asleep, such as walking, eating, or driving. On melatonin, NHLBI says its effectiveness is not proven and it can cause daytime sleepiness, headaches, and upset stomach.

NCI adds that these medicines should be tapered slowly rather than stopped abruptly, because sudden withdrawal can disturb sleep patterns further.

• Poor sleep has lasted more than a few weeks, or is getting worse.
• Pain, nausea, hot flashes, or needing to urinate are what wake you. These are treatable causes.
• You snore heavily, gasp, or stop breathing in your sleep, or someone tells you that you do.
• You feel very weak and tired even after resting or sleeping, or you cannot do your usual activities. NCI names this specifically as something to report.
• You are low, hopeless, or anxious most of the day as well as at night.
• You are taking anything to sleep, including over-the-counter products, that the team does not know about.

• Is one of my medicines likely causing this, and can the timing be moved?
• Can you refer me for CBT-I, and is there an online or telephone option?
• Is my pain or nausea well enough controlled overnight?
• Should I be napping, given how my days are going?
• If we try a sleep medicine, for how long and how will we stop it?
• Could this be sleep apnea rather than insomnia?

Read next: Cancer Anxiety and Uncertainty, Managing Stress During Cancer, Walking Plan After Chemotherapy, and Stretching After Cancer Surgery: What to Ask.

• Call 911 or go to an emergency department if the sleepless nights have brought thoughts of ending your life. You can also reach the 988 Suicide & Crisis Lifeline by call, text or chat at any hour.
• Call your care team the same day if a partner watches your breathing stop while you sleep, or you jolt awake gasping and then cannot stay awake through the day.
• Call your care team within a day or two if poor sleep has run on for weeks or is getting worse, if pain or nausea is what wakes you, or if you feel low or hopeless most of the day as well as at night.

• https://www.cancer.gov/about-cancer/treatment/side-effects/sleep-disorders-pdq
• https://www.cancer.gov/about-cancer/treatment/side-effects/sleep-disorders-hp-pdq
• https://www.cancer.gov/about-cancer/treatment/side-effects/fatigue
• https://www.nhlbi.nih.gov/health/insomnia/treatment
• https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know
• https://988lifeline.org/