Sleeping Well

Also known by these names

  • Rest
  • Sleep hygiene

better quality of life and reported significantly less fatigue

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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.

Authors

Laura Pole, RN, MSN, OCNS, BCCT Senior Researcher

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Nancy Hepp, MS, BCCT Project Manager

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Last updated September 23, 2021.

Improving your sleep quality is one step you can take to improve your resilience and well-being. It may possibly improve your response to treatment, also.

The Importance of Sleeping Well

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).

Highlighted Video

BCCT Senior Researcher Laura Pole, RN, MSN, OCNS, explains the importance of sleep in cancer care.

  • Worse survival, plus more interference with function, more anxiety and depression, poorer nighttime sleep, more daytime fatigue, and poorer quality of life among people with advanced lung cancer suffering greater circadian activity/sleep cycle disruption compared to those who maintained good circadian integration1
  • Substantially longer survival, plus better quality of life and less fatigue among people with metastatic colorectal cancer who had marked rest/activity rhythms in a mid-sized observational study2
  • Higher levels of anxiety, fatigue, and depression were linked to poorer sleep quality among adults with multiple sclerosis in a mid-sized observational study.3

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

Health Effects of Poor Sleep Quality

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:4

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Electromagnetic Fields and Sleep

Electromagnetic fields (EMFs) may interfere with sleep-activity cycles—your circadian rhythms. The idea is considered controversial, but some evidence shows that EMFs may affect melatonin metabolism and circadian rhythms.

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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.8

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.9

Cancer

An extensive meta-analysis did not find an overall association between ever-exposure to night-shift work and the risk of several types of cancer (breast, prostate, ovarian, pancreatic, colorectal, non-Hodgkin's lymph, and stomach cancers).10 However, some studies have concluded that rotating schedules and many years of shift work are linked to increased risk of some cancers, especially breast cancer.11

Cancer patients also report insomnia at twice the rate as the general population.12

Cortisol, Sleep and Cancer

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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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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.26

Treating the Cancer

Working against cancer growth or spread, improving survival, or working with other treatments or therapies to improve their anticancer action

Your treatment and wellness outcomes can benefit from achieving more normal circadian (sleep and rest) patterns.27 See Timing of Therapies: Chronomodulation and Metronomic Dosing.

  • Dramatically longer survival—a 50 percent higher five-year survival rate— and improved response to treatment among people with metastatic colon cancer who have restful sleep between 11pm and 7am28
  • People with metastatic colon cancer with the most abnormal sleep/activity rhythms were five times more likely to die within two years after their diagnosis29
  • Chronomodulated therapy may not be as effective when sleep-rest (circadian) rhythms are disrupted by chemotherapy,. Chemotherapy-induced fatigue and weight loss—both of which are related to poor sleep quality—early in therapy may impair the benefits of chonomodulated therapy on survival and time to progression.30

Managing Side Effects and Promoting Wellness

Managing or relieving side effects or symptoms, reducing treatment toxicity, supporting quality of life or promoting general well-being

  • 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.31
  • Better quality life and less fatigue were seen in metastatic colorectal cancer patients with normal 24-hour rest/activity rhythms than those with altered rhythms32
  • Sleep disruption leads to increased symptoms of depression in men with prostate cancer, possibly through dysregulating the stress response.33
  • Improved function and fewer disease symptoms among people with metastatic colon cancer who have restful sleep between 11pm and 7am34
  • More severe acute pain after surgery among women who had sleep disturbance before breast cancer surgery in a mid-sized observational study35

Reducing Risk

Reducing the risk of developing cancer or the risk of recurrence

A 2014 review concluded that maintaining a regular and adequate daily amount of sleep contributes to prevention of colorectal cancer.36 A 2013 review reported that women and men chronically exposed to night-shift work have a 50 percent increased risk of developing colorectal cancer compared to day-shift workers.37  However, long sleep duration—sleeping nine or more hours per night—is also associated with an increased risk of colorectal cancer.38

The Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons recommends regular sleep after curative treatment of colon and rectal cancer.39

Interrupted sleep caused by obstructive sleep apnea is associated with a higher risk of melanoma, pancreatic cancer and kidney cancers, but lower risk of breast, prostate or colorectal cancers.40

Optimizing Your Terrain

Creating an environment within your body that does not support cancer development, growth or spread

Blood Sugar and Insulin Resistance

According to BCCT advisors, consistently poor sleep (and even too much sleep) can lead to insulin resistance, as well as many other physical and mental health issues.41

  • CPAP use to address sleep apnea is linked to improved HbA1c, fasting glucose, and homeostatic model assessment of insulin resistance (HOMA-IR) levels across several studies.42
  • Interventions promoting sleep quality (CBT-I and sleep education) led not only to better self-reported sleep quality but also weak trends toward lower hemoglobin A1c level and fasting glucose levels43

Inflammation and Oxidation

Cytokines are proteins with a complex relationship to your immune system and sleep cycles. If your circadian rhythm is disrupted by an external change in the light-dark cycle—such as by night-shift work or staying awake late at night—your immune cells produce a heightened proinflammatory response driven in part by cytokine release..44

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.45

In patients with metastatic colorectal cancer, higher levels of inflammatory cytokines were linked to disrupted rest/activity circadian rhythms. Higher cytokine levels were associated with poorer response to chronochemotherapy (chemotherapy timed by circadian rhythms), poorer survival, increased fatigue and loss of appetite.46

Therapies that reduce inflammation and promote more typical sleep-activity rhythms may impact cytokine release and improve outcomes.

Sleep deprivation was associated with a significant unbalance in histone activity—important for regulation of genes—as well as oxidative stress and ongoing inflammation in animal studies.47  

Your Microbiome

Lack of sleep (sleep restriction) did not influence the gut microbiome much in either humans or animals.48

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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Balancing Sleep/Rest/Activity Biorhythms

One behavioral adjustment—timing of bedtime—may improve sleep duration. For example, going to bed before midnight is associated with longer sleep in ovarian cancer survivors in the first six months following treatment.53

Noted integrative cancer specialists and BCCT advisors Keith Block, MD, and Lise Alschuler, ND, FABNO, suggest further actions for balancing sleep, rest and activity and promoting restful sleep, including these:54

  • Practice good sleep hygiene:

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Activity and Sleep

When you exercise or are more active can impact not only your fitness and metabolism, but your sleep and your response to cancer treatments.

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about how and when to be active to promote normal circadian (sleep-rest) function.57
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Preparing Your Mind for Sleep

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about how to prepare your mind to promore better sleep59

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Food and Sleep

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.60

When you eat can impact not only your digestion, absorption of nutrients and metabolism, but your sleep and your response to cancer treatments.

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance about what and when to eat to promote normal circadian (sleep-rest) function.61

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Integrative Therapies to Improve Sleep Quality

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.62

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.6364

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.”65 However, the following evidence has come forth since that review regarding acupuncture and hot flashes:

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Natural Products

Evidence of effectiveness is summarized on the linked therapy summaries.

Mind-Body Approaches

Evidence of effectiveness is summarized on the linked therapy summaries.

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

Manipulative and Body-based Methods

Evidence of effectiveness is summarized on the linked therapy summaries.

Diets & Metabolic Therapies

  • 14 straight hours of fasting each day

Special Guidance for People with Cancer

Integrative oncologist and BCCT advisor Keith Block, MD, and his colleagues offer guidance to promote normal circadian (sleep-rest) function among people in chemotherapy treatment, with advanced disease, or experiencing wasting (cachexia).75

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Addressing Inflammation

Reducing inflammation in cancer patients with integrative therapies has improved fatigue.

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

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

Commentary

From BCCT advisor Ted Schettler, MD, MPH, March 4, 2019: Lavender oil (as with some other essential oils) has estrogenic properties at some concentrations.81 It might be wise to avoid skin application of lavender oil in the setting of an estrogen positive breast cancer diagnosis.

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More Information

Aids & Advice for Improving Sleep

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Government Sites

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Other Websites

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Finding a Sleep Specialist

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More from Our Resources Database

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