Sleeping Well

Also known by these names

  • Rest
  • Sleep hygiene

The Importance of Sleeping Well

Key Points

  • Restful sleep is critically important to healing, well-being and quality of life.
  • BCCT is interested in restful sleep because research shows impacts on risk of cancer, cancer progression and survival, response to treatment, mood and pain.
  • Insomnia is common, and even more so among cancer patients.
  • Several lifestyle choices can impact sleep.
  • BCCT advisors suggest behavioral, dietary, movement, mind-body and natural products approaches to promoting restful sleep.

Getting adequate sleep and rest is considered an essential lifestyle strategy to include in an integrative cancer care plan. Integrative cancer care specialists such as Keith Block, MD; Gary Deng, MD; Lise Alschuler, ND, FABNO; and Nasha Winters, ND, FABNO, all emphasize the importance of balancing one’s biorhythms (also called circadian rhythms) to create an internal environment that is hostile to cancer cells while also promoting healing and health. The sleep/rest/activity cycle is one of those rhythms. Dr. Deng considers sleep as one of the 6 Pillars of Good Health (the others being exercise, diet, stress management, relationships and meaning).

Sleep (especially sleep at night) is the time when our bodies maintain optimal functioning of our immune, cellular, metabolic and endocrine (hormonal) systems. For more information about the importance of sleep, see the National Heart, Lung and Blood Institute's page: Why Is Sleep Important?

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Insomnia

Melatonin, Light and Sleep

Melatonin is produced naturally by the pineal gland during the early hours of night, signaling and initiating the transition from wakefulness to sleep. Individuals who experience sleep difficulties may have disrupted melatonin production.

One factor that influences melatonin production is bright light. Such light exposure late in the evening—and especially blue-spectrum light such as from most television, computer, mobile phone and other screens—can disrupt melatonin production and delay the initiation of sleep. Treatments for sleep disruptions such as delayed sleep-wake phase disorder may curtail exposure to bright and blue-spectrum light in the evening.

During the day, melatonin production diminishes as our production of serotonin and cortisol increase. Bright light in the morning boosts serotonin and cortisol while also diminishing melatonin production, leading to greater wakefulness and setting the stage for the next evening's production of melatonin.

To optimize our natural melatonin cycles and benefits, research indicates that we should curb bright light in the evening and increase bright light exposure in the morning.2 Preliminary research also shows that bright light therapy in the morning can improve sleep in people with cancer.3

Many people in modern society now suffer from insomnia, which is marked by these symptoms:

  • Difficulty falling asleep
  • Early awakening
  • Frequent nighttime waking and inability to get back to sleep for an hour or two
  • Not feeling refreshed in the morning

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Health Effects of Poor Sleep Quality

General Health

Inadequate sleep at night leads to these physical responses:

  • Low levels of melatonin, a hormone naturally produced in the pineal gland that helps regulate sleep and wake cycles.
  • Elevated blood cortisol levels are usually low at night but are often elevated in those with chronic sleep disruption.5
    Chronic elevations in blood cortisol and adrenaline can cause physical changes that impact health and functioning. These changes are sometimes referred to as “weathering” of the body, akin to the weathering of a flag in a consistent high wind.6

Cancer

When circadian rhythms are disrupted by conditions such as shift work, short sleep duration, and exposure to light at night, we see increased risk of several cancers:7

  • In women:
    • Breast cancer
    • Ovarian cancer
  • In men:
    • Bladder cancer
    • Colorectal cancer
    • Lung cancer
    • Non-Hodgkin’s lymphoma
    • Prostate cancer
    • Pancreatic cancer

 Evidence of links between sleep and cancer:

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Clinical Practice Guidelines

2009 evidence-based clinical practice guidelines for integrative oncology: “Any of the techniques, such as relaxation, meditation, and imagery, as well as autogenic training hypnosis, self-expression, and exercise, provide specific psychological and physiologic benefits, that is, decreases in stress; improvements in sleep, mood, and pain; a decrease in stress hormones; and improvement in immunity.” Evidence also supports use of Mindfulness-Based Stress Reduction (MBSR), yoga, and psychological interventions including behavioral therapies.21

Treatments to Improve Sleep Quality

Managing Insomnia

Neuropsychologist Michael Howard, PhD, lectures to healthcare professionals on understanding and managing sleep disorders. He advocates first determining if presenting insomnia is primary or secondary, for the causes and remedies are different:22

  • Primary insomnia is an independent sleep disorder and typically linked to thinking and worrying, two brain processes that prevent the activation system of the brain from responding to normal signals for sleep.
  • Secondary insomnia is caused by physical or psychosocial events or issues including these:
    • Shift work
    • Job loss
    • Divorce
    • Emotional problems such as depression
    • Environmental conditions such as a warm room
    • Symptoms such as hot flashes, fever or pain

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Improving Sleep

Conventional Approaches

A 2009 review found that behavioral therapies maintain longer-term improvement in sleep quality compared to pharmaceuticals.

In conventional medicine, insomnia and sleep disruption are often treated with sleep medications which may help temporarily but don’t address the underlying cause, can be habit-forming and may even increase risks of death from a variety of causes including overdose, infections, cancer, depression and suicide, automobile crashes, falls, and other accidents, and hypnotic-withdrawal insomnia.25

Complementary Approaches

A 2009 review found that behavioral therapies maintain longer-term improvement in sleep quality compared to pharmaceuticals.26

Eating Well

A pilot randomized study of a fatigue-reduction diet rich in fruit, vegetables, whole grains and omega-3 fatty acid-rich foods improved sleep and fatigue in women with breast cancer compared to a control group receiving general health information.27

Natural Products
Mind-Body Approaches
  • Two elements of Cognitive Behavioral Stress Management (CBSM)—relaxation training and cognitive restructuring—target sleep and fatigue. A randomized control trial of CBSM in women undergoing primary treatment for breast cancer demonstrated greater improvement in sleep quality and fatigue than those in a control group.36
  • Cognitive Behavioral Therapy for Insomnia (CBT-I) for eight weeks was effective in treating moderate to severe insomnia and more effective than acupuncture for those with mild symptoms of insomnia. Both therapies also improved quality of life.37
  • Qigong, a component of traditional Chinese medicine, has reduced stress levels with improved sleep quality, activity levels, immune response and balance in older adults.38
Manipulative and Body-based Methods
  • Acupuncture was effective in treating moderate to severe insomnia and also improved quality of life.39
  • Massage, whether with or without aromatherapy, was associated with better sleep In a randomized control trial of people with advanced cancer in a hospice setting.40

Reducing Hot Flashes as a Barrier to Sleep

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Addressing Inflammation

Michael Irwin, MD, of the UCLA Department of Psychiatry and Biobehavioral Sciences prefers not to use anti-inflammatory drugs to reduce inflammation in cancer patients due to multiple side effects. He has researched several mind-body approaches and found these are useful in improving or reversing insomnia and subsequently improving inflammatory markers:

  • Mindfulness meditation
  • Tai chi
  • Yoga meditation
  • Yoga
  • Stress reduction practices

Other symptoms such as depression and fatigue also improved.46

Balancing Sleep/Rest/Activity Biorhythms

Noted integrative cancer specialists Keith Block, M, and Lise Alschuler, ND, FABNO, suggest actions for balancing sleep, rest and activity and promoting restful sleep, including these:47

  • Practice good Sleep Hygiene:

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Access

Many of the strategies for improving sleep are available through books, websites, group classes or private lessons. If you decide to use diet and supplements to help with your sleep, consulting with a healthcare professional who is experienced in prescribing diets and supplements for cancer patients—such as an integrative oncology physician, a naturopathic oncologist, an oncology dietitian or clinical nutritionist—could be helpful.

Cautions

Mind-body approaches to helping with insomnia are generally considered safe.

If you decide to take natural products to assist with sleep, consult with your pharmacist or healthcare provider to see if any contraindications, side effects or drug-herb or herb-herb interactions arise. Let your cancer care team know if you are taking any natural products such as herbs or supplements.

Integrative Plans, Protocols and Medical Systems

For more information about protocols, see our Protocols and Integrative Plans page.

Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; most recent update on February 12, 2019.

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