Web Exclusive: Sleep Difficulties in Cancer Patients

Restorative “good night” sleep is an essential need for all humans. The feeling of being rested and refreshed in the morning gives us a sense of renewal and well-being. But cancer patients seem to be more prone to disturbed sleeping patterns, such as difficulty falling asleep, staying asleep and early awakening. These sleep disturbances can result in a variety of symptoms, such as increased fatigue, irritability, reduced concentration and attention span, memory lapses, decreased tolerance to pain and stress.

Although most oncologists generally agree sleep difficulties are common among cancer patients, and the World Health Organization has proclaimed sleep improvement a primary aim in its cancer pain relief effort, the prevalence and nature of cancer patients’ sleep problems is still unclear.

At the Cross Cancer Institute, a comprehensive cancer center in Canada, we studied a sample of advanced cancer outpatients attending clinic. The majority of the participants (72 percent) reported a wide variety of sleep problems after their cancer diagnosis, while only 19 percent reported experiencing such difficulties before their diagnosis. Seventy percent of patients indicated they did not feel rested in the morning, 40 percent experienced difficulties initiating sleep, 63 percent had frequent awakening during the night and 37 percent reported early morning awakening and inability to fall asleep again.

More than half (52 percent) said they slept too few hours by their standards as compared with 31 percent who felt they were sleeping too many hours. A majority said their sleep disturbances occurred at least five nights a week and they lay in bed unable to fall asleep for at least two hours every night.

More than half of patients identified a variety of coping strategies that they had tried to remedy their sleeping problem. The most frequent coping techniques used were relaxation, visualization and prayer. Eleven percent of the patients indicated they may have used at least one of these techniques with an effectiveness average score of 5.5 out of 10. Sleep medication was the treatment of choice for 37 percent of the participants with moderately high effectiveness.

It is possible that amid the myriad of symptoms cancer patients experienced as a result of their illness and its treatment, sleeping difficulties may be perceived as trivial or less important. Patients may view their sleep deficiencies as relatively minor inflictions in their cancer ordeal, inconvenient but bearable. Some patients may also be reluctant to initiate “frivolous” complaints that may distract their medical team from curative efforts. Patients’ reluctance to report their sleep difficulties is compounded by the fact that sleep disturbances are a subjective experience with few visible signs. Consequently, some oncologists may overlook or even discount sleeping difficulties as expected consequences of having cancer. As a result, underrecognized and underreported sleep problems are often are underdiagnosed and undertreated.

The major thrust of sleeping disorders research in recent years has been that sleeping problems are usually not disorders, but rather symptoms triggered by underlying medical or psychological conditions, such as anxiety or depression. In treatment, it is therefore important to distinguish between short-term and long-term insomnia.

Short-term insomnia is considered to last only a few weeks and is associated with external stressors, such as work or family issues. In the case of short-term insomnia, initiating and maintaining sleep can often be improved by applying non-medicated treatment or therapy. That may include educating and instructing patients in the principles of sleep hygiene. The non-drug treatments are designed to help patients take a more active stance about their sleep difficulties, rather than view themselves as passive victims. For long-term insomnia, however, determination, sleep hygiene and cognitive behavioral approaches are usually not sufficient. The most effective treatment for long-term sleeping problems appears to be a combination of prescribed sleeping medications with the non-drug techniques.

Many cancer patients are hesitant to take additional medication because they are concerned about dependency. However, in most cases a risk-benefit analysis will demonstrate the advantages of obtaining a restorative, uninterrupted, quality sleep and its positive impact on the patients’ well-being and functioning level far outweigh any known risks. Over time, developing new sleep habits will bring relief from long-term insomnia without medication.

Rami A. Sela, PhD, is a professor of oncology at the University of Alberta and director of the department of psychosocial and spiritual resources at Cross Cancer Institute in Edmonton, Alberta, Canada.