Sleeping Well
Also known by these names
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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.
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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).
One study found that patients with advanced lung cancer suffering greater circadian activity/sleep cycle disruption suffer greater interference with function, greater anxiety and depression, poorer nighttime sleep, greater daytime fatigue, and poorer quality of life than comparable patients who maintain good circadian integration.
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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Good sleep is necessary not only for physical health, but for mental and emotional health as well. Poor sleep, or even too much sleep, is linked to many physical, mental and emotional problems:
Good sleep is necessary not only for physical health, but for mental and emotional health as well.
- Weakened immunity
- Insulin resistance
- Inflammation
- Impaired digestion and detoxification
- Changes in gut bacterial balance
- Obesity
- Depression
- Fatigue
- Irritability
- Anxiety
- Chronic diseases including cancer
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.
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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. Preliminary research also shows that bright light therapy in the morning can improve sleep in people with cancer.
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Electromagnetic Fields and Sleep
Electromagnetic fields (EMFs) may possibly have a detrimental effect on circadian rhythms, although the idea is controversial. Some evidence suggests that EMFs may affect melatonin metabolism and the circadian rhythm:
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- A 2017 review found an effect of 900-MHz and 60-Hz EMF on melatonin metabolism and the circadian rhythm.
- A 2014 review concluded that “despite divergences in the reported results, ELF-MF and radio frequency electromagnetic field have to be considered as factors possibly influencing the circadian system function, because a substantial number of studies demonstrated the changes in melatonin and cortisol secretion as well as in sleep after exposition to these fields.”
- A 2013 study found that weak EMFs disrupt melatonin and change the circadian rhythm.
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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, usually low at night but often elevated in those with chronic sleep disruption.
Chronically elevated 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..
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:
Cancer patients also report insomnia at twice the rate as the general population.
In adults with cardiovascular and cerebrovascular diseases, sleeping less than six hours a night was associated with almost triple the risk of cancer mortality compared with sleeping six or more hours a night.
Cortisol, Sleep and Cancer
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- Cancer incidence, progression and mortality are linked to stress and disruption of the circadian (daily) rest and activity cycle. Cortisol, our primary stress hormone, helps regulate the sleep-wake cycle. Cortisol in excess pushes several cancer processes forward, especially metastasis. Melatonin, the “sleep hormone”, is instrumental in eliminating cancer cells and reducing the side effects of chemotherapy. However, when hours normally spent sleeping are supplanted with activities such as looking at a smartphone, computer or TV screen or working night shifts, melatonin is suppressed.
- A rise in blood cortisol in response to stress or poor sleep quality can speed up tumor growth. Cortisol suppresses immunity, which is critical in mopping up malignant cells that remain after cancer treatment.
- The combination of cortisol and adrenaline increases blood glucose levels. Chronic high blood glucose episodes can be a direct or indirect mediator of the increase in tumor cell growth.
- Cortisol also increases insulin resistance and seems to stimulate the ability of some cancer cells to grow and metastasize.
- Breast cancer patients who don’t have normal cortisol rhythms have less-active natural killer cells and have reduced survival compared to others.
- Although the mechanisms are not yet known, high cortisol levels and disrupted sleep-wake cycles are connected to these outcomes:
Sleep and Cancer Treatment
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- Patients with metastatic colon cancer who have restful sleep between 11pm and 7am have responded better to treatment. They also function better, don’t have as many disease symptoms, and have dramatically longer survival. In one study, those with the most abnormal sleep/activity rhythms were five times more likely to die within two years after their diagnosis.
- Disrupted sleep, which is a sign of disrupted stress hormone rhythms, seems to make side effects of chemotherapy more intense, whereas good-quality sleep and normal rhythms can minimize these side effects.
- Chronic inflammation is linked to sleep disturbance. Cancer treatment itself causes a marked increase in inflammation which can result not only in impaired sleep, but also depression, fatigue and cognitive dysfunction. Impaired sleep can then increase inflammation. Chronic inflammation is linked to higher cancer mortality.
Sleep and Cancer Outcomes
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- Cancer acts more aggressively in people with low nighttime production of melatonin. Cancer patients with high melatonin levels tend to have better outcomes.
- Colorectal cancer patients who had normal sleep-activity rhythms had a 50 percent higher five-year survival rate.
Sleep and Quality of Life
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- 2016 study suggested that sleep disruption leads to increased symptoms of depression in men with prostate cancer, possibly through dysregulating the stress response.
Quality sleep is most likely beneficial across a wide range of cancers, even though research to date may focus on only a few cancer types. Restful sleep, like several other lifestyle-related practices, generally involves very little risk, may improve quality of life and possibly improve cancer outcomes, and many practitioners are comfortable recommending this for patients.
Clinical Practice Guidelines
2009 evidence-based clinical practice guidelines for integrative oncology state: “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.
Managing Insomnia
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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Lise Alschuler, ND, FABNO, says that many factors can interfere with the quality of our sleep: “These include unresolved stress, a noisy bedroom environment, too much light in the bedroom, a bedroom that is too warm, hormonal issues such as hot flashes, too much alcohol, insufficient protein in the evening meal and side effects of medications.
Often insomnia is related to lifestyle choices and situations that take us away from our natural rhythms and that promote inactivity.
Often insomnia is related to lifestyle choices and situations that take us away from our natural rhythms and that promote inactivity:
- Overeating, or eating foods that interfere with sleep promotion, or eating late in the evening
- Staying up late and “screening”—looking at TV, computer and cell phone screens for long hours, especially late in the evening
- Overwork or nighttime work
- Chronic unmanaged stress
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:
- 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
Secondary insomnia is far more common; the best way to manage it is to address the condition/symptom preventing quality sleep.
Immediately resorting to sleep medications for either type of insomnia is typically not optimal, as these medications are effective less than 10 percent of the time, they compromise one or more of the sleep cycles, and they come with side effects, some serious.
Of most benefit for primary insomnia are the psychological/behavioral/cognitive therapies that change thinking patterns and reduce worrying. Dr. Howard suggests the following steps for patients to manage primary insomnia:
- Practice good sleep hygiene (see the section on Balancing Sleep/Rest/Activity Biorhythms below).
- If more intervention is needed, seek professional help if the following three statements apply:
- The insomnia has lasted more than three weeks.
- It is not improving.
- It is interfering with your ability to function during the day.
- Consider working with a sleep specialist—a healthcare professional, typically in the medical or psychology fields, with specialty training in sleep medicine and sleep disorders.
- If the sleep specialist determines that primary insomnia is the problem, consider therapies/practices that deal with the thinking/worrying:
- Cognitive-behavioral therapy (CBT) and counseling
- Specific relaxation and exercise practices
- Behavioral conditioning
Integrative Therapies to Improve Sleep Quality
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:
- Practice good sleep hygiene:
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- Keep your bedroom dark, cool and quiet.
- Exercise daily.
- Maintain a regular schedule of sleep, work, physical activity, bedtime and waking.
- Limit daytime naps to 30 minutes.
- Avoid caffeine and excessive alcohol consumption.
- Avoid strenuous exercise or heavy meals for several hours before bedtime.
- Establish a regular relaxing bedtime routine.
- Practice a calming and meditative exercise, such as yoga, in the evening.
- Ensure adequate exposure to natural light (sunlight in the day and darkness at night)
- Consider using herbs or dietary supplements if needed (see Natural Products above)
- Work in partnership with your doctor to assess and monitor hormone imbalances; this may involve lab tests.
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While both conventional and complementary options are available, a 2009 review found that behavioral therapies maintain longer-term improvement in sleep quality compared to pharmaceuticals.
Conventional Approaches
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, hypnotic-withdrawal insomnia, and automobile crashes, falls, and other accidents.
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.
Reducing Hot Flashes as a Barrier to Sleep
A 2009 review concluded that “acupuncture does not appear to be more effective than sham acupuncture for treatment of vasomotor symptoms (hot flashes) in postmenopausal women in general.” However, the following evidence has come forth since that review regarding acupuncture and hot flashes:
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- A study in 2015 found that electroacupuncture (EA) with breast cancer patients may be more effective in reducing hot flashes than the prescription drug gabapentin, and with fewer side effects. EA was also shown comparable to gabapentin for improving sleep quality in women experiencing hot flashes.
- Early phase studies suggest that acupuncture may relieve hot flashes in prostate cancer patients.
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Natural Products
Mind-Body Approaches
A 2009 review found that behavioral therapies maintain longer-term improvement in sleep quality compared to pharmaceuticals.
- 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.
- 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.
- Qigong, a component of traditional Chinese medicine, has reduced stress levels with improved sleep quality, activity levels, immune response and balance in older adults.
- Sleep Training Education Program: Both STEP‐1 (a single sleep education session) and STEP‐2 (a three‐session, group cognitive behavioral treatment) improved Insomnia Severity Index (ISI) scores, with substantial remission of insomnia among cancer survivors in a small study. This therapy can be administered by non sleep-specialists, making it accessible to more patients.
Manipulative and Body-based Methods
- Acupuncture was effective in treating moderate to severe insomnia and also improved quality of life.
- 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.
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:
Other symptoms such as depression and fatigue also improved.
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 Programs, Protocols and Medical Systems
- Integrative programs and protocols
- Alschuler & Gazella complementary approaches
- Block integrative cancer care program
- Cohen & Jefferies Mix of Six anticancer practices
- Geffen Seven Levels of Healing
- MacDonald breast cancer program
- Traditional systems
From BCCT advisor Ted Schettler, MD, MPH, March 4, 2019: Lavender oil (as with some other essential oils) has estrogenic properties at some concentrations. It might be wise to avoid skin application of lavender oil in the setting of an estrogen positive breast cancer diagnosis.
Written by Laura Pole, RN, MSN, OCNS, and Nancy Hepp, MS; most recent update on October 20, 2019.
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More Information
- I-Heart Radio:
- Lonestar Medical Group Patient Education webpage: Insomnia
- NCI: Sleep Problems and Cancer Treatment
- Finding a sleep specialist:
- National Heart, Lung and Blood Institute: Innsomnia.
- Medscape: OTC Insomnia Supplements: The Latest Evidence
- Matt Walker: Sleeping Enough to Be Truly Awake
- helpsyhealth.com: Helpsy Health
- Andrew Weil Center for Integrative Medicine: CanHEAL
- Integrative Cancer Review
- Martin L. Rossman, MD: Fighting Cancer from Within
- Lise Alschuler and Karolyn A. Gazella: iThrive Plan
- Barbara MacDonald, ND, LAc: The Breast Cancer Companion: A Complementary Care Manual: Third Edition
- September 2018 Issue of the Journal of Alternative and Complementary Medicine
- Wayne Jonas, MD: Your Healing Journey: A Patient’s Guide to Integrative Breast Cancer Care
- American Society of Clinical Oncology: Cancer.Net
- Donald I. Abrams, MD, and Andrew T. Weil, MD: Integrative Oncology, 2nd Edition
- Lise Alschuler, ND, FABNO, and Karolyn Gazella: The Definitive Guide to Cancer, 3rd Edition
- Keith I. Block, MD: Life over Cancer: The Block Center Program for Integrative Cancer Treatment
- Lorenzo Cohen and Alison Jefferies: Anticancer Living: Transform Your Life and Health with the Mix of Six
- Jeremy R. Geffen, MD, FACP: The Seven Levels of Healing®: Celebrating Life and Spirit on the Journey through Cancer
- Martin L. Rossman, MD: The Healing Mind
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