Dr. Barrie Cassileth Chief of Integrative Medicine MSKCC. Mind body therapy, medication, exercise, CAM all play a role.
Many cancer patients face sleep problems, such as difficulty falling asleep, frequent nighttime waking, rising too early in the morning, or excessive sleeping during the day. Such symptoms may occur in more than 70 percent of people with cancer. Stress and anxiety about one’s diagnosis, side effects of treatment, and many other factors can contribute. Moreover, poor sleep may contribute to other symptoms, such as fatigue or mood disturbances.
There are various medications to treat insomnia that work quickly and effectively, but they have their own side effects, including the risk of dependence. Many individuals also advocate various supplements, and alternative approaches. Integrating these with "good sleep "hygiene" can help solve insomnia. Most recently some cancer centers are implementing Cognitive Behavioral Therapy as part of a comprehensive approach.
Medications to Treat Insomnia
Medications can be used to help manage insomnia. Medications should be used in combination with good sleep practices and under the supervision of a physician. All of the following medications are taken shortly before going to bed.
Specific Sleep Medications:
- Zolpidem (Ambien, Edular, Intermezzo): These medicines help individuals fall asleep but often don't help them stat asleep. There is now an extended release version of Ambien that helps individuals stay asleep longer.
- Eszopiclone (Lunesta): Lunesta helps individuals both fall asleep quickly, and studies show people sleep an average of 7 to 8 hours.
- Doxepine (Silenor): Silenor blocks histamine and is approved for use in people who have trouble staying asleep.
- Suvorexant (Belsomra): Belsomra blocks a hormone that promotes wakefulness and causes insomnia but often causes individuals to feel sleepy the following day.
- Ramelteon (Rozerem): Works by targeting the sleep-wake cycle, not by depressing the central nervous system like many of the other medications. It is often prescribed for long-term use, and the drug has shown no evidence of abuse or dependence.
- Zaleplon (Sonata): Sonata stays active in the body for the shortest amount of time which makes it useful for falling asleep but not for staying asleep.
Quviviq (daridorexant): an orexin receptor antagonista was approved by the US FDA for the treatment of adults with insomnia characterized by difficulties with sleep onset and/or sleep maintenance in May 2022.
Approval was based on two phase 3 studies that showed daridorexant demonstrated statistically significant and clinically meaningful improvements in sleep onset, sleep maintenance, and patient reported total sleep time. Patients treated with daridorexant also had a significant reduction in daytime sleepiness, as assessed by a validated sleep diary questionnaire.18,19
It should be noted the certain anti-depressant and anti-anxiety medications can also be helpful sleep aids as can come over the counter medications. Most over the counter sleep aids are antihistamines which cause drowsiness. They can create a sluggish feeling the next day and are notorious for causing dry mouth.
Can OTC Supplements Help Manage Insomnia?
The American Academy of Sleep Medicine (AASM) reviewed the evidence for OTC sleep aids used for Insomnia.1
Melatonin is a popular dietary supplement used by many patients to fall asleep faster. Despite melatonin being commonly studied for the treatment of insomnia few well conduced clinical trials have been performed to evaluate its effectiveness. The AACM analyses of clinical trials suggests that it decreases the time it takes to fall asleep (sleep latency) by 5-9 minutes, and that patients with delayed sleep phase syndrome seem to fall asleep even faster. Studies have not identified significant side-effects. Melatonin does not appear to cause “hangover” or withdrawal symptoms, which are often reported with prescription drugs.1,2,3
Benadryl and other antihistamines have somnolence as a side effect and individuals sometimes use them to help sleep. They are however not FDA approved for this indication.
L-Tryptophan - low-quality studies published in the 1970s and 1980s provided some evidence that it can improve insomnia.(8) More recently a clinical trial comparing L-tryptophan from either food or supplement sources to placebo in a small group of patients with chronic insomnia found that L-tryptophan in supplement form led to significant improvements in total sleep time (+42 minutes), sleep efficiency (+7.3%), total awake time (-35 minutes), and sleep quality when compared with baseline measurements. However, patients receiving placebo also had significant improvements in many of these metrics, and no significant differences between L-tryptophan and placebo were reported. Because L-tryptophan is a precursor of serotonin it can interact with several antidepressant medications and other drugs with serotonergic effects. Patients who choose to take L-tryptophan for insomnia should discuss drug interactions with their treating physician.4,5,6
Valerian trials assessing the utility of valerian for treating insomnia suggest that valerian offers no clinically meaningful improvement in sleep latency, total sleep time, or sleep quality compared with placebo.1,7,8
Cannabidiol (CBD) is generally well tolerated and research on insomnia is mixed. Taking 160 mg of CBD before bedtime significantly improved total sleep time over placebo in patients with insomnia in one study from the 1980s. Sleep duration was not improved with 40-mg and 80-mg doses. Taking 300 mg of CBD 30 minutes before a sleep study did not improve total sleep time, sleep latency, or sleep quality over placebo in healthy patients.9,10
Chamomile There is limited research and what has been reported does not confirm that it improves insomnia. It is generally well tolerated but does alter the metabolism of several other medications.11
Kava Short-term use of kava is generally safe and well tolerated. However, reports of hepatotoxicity have been linked to kava. Taking 70 mg of kavalactones each evening for 4 weeks significantly improved sleep quality over placebo in patients with sleep problems related to anxiety. Taking 100 mg of kavalactones three times daily for 4 weeks did not improve insomnia symptoms in patients with symptoms of anxiety and insomnia.8,10,12
Lavender Aromatherapy with lavender has improved measures of sleep quality in some studies, but other research has found no significant improvement in sleep parameters over placebo. There are no major reported safety concerns or drug interactions.10
Intensive Cognitive Therapy
New research suggests that chronic insomnia in cancer survivors can be effectively treated with intensive cognitive behavioral techniques.
Cognitive behavioral therapy (CBT) for insomnia is a form of talk therapy that helps patients understand the maladaptive sleep behaviors and thought patterns that cause their insomnia to persist—and teaches them to adopt healthier behaviors and change their thoughts at night.
Doctors from the Dana-Farber Cancer Institute have reported that a single-session sleep education program for cancer survivors can cure insomnia in many participants, and that those who don't benefit from this approach are often helped by a more extensive, but still modest, three-session program. Using the one-time sleep education program 41% of cancer survivors with insomnia were successfully treated and this improved to 71% in individuals completing the three - session program.
The difficulty sleeping that many survivors experience often originates during treatment for their cancer, as a result of a combination of factors including their anxiety, fatigue, or pain. While these problems may diminish or disappear after treatment, insomnia often lingers,
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The first step one-session sleep education class was designed so that it could be easily implemented by a small cancer center with limited resources or staff. Much of the material covered in the session is not especially advanced and can be found on “tips for sleeping” handouts commonly available at primary care clinics and cancer centers.
The second step of the model needs to be led by a clinician trained in CBT for insomnia and is offered in a group setting, rather than a one-on-one consultation.
Complementary and Alternative Approaches
Complementary approaches, such as relaxation and tai chi, take more time to learn but may lead to longer-term improvements in sleep quality. Although research on complementary therapies for insomnia and other forms of sleep disturbance specifically in cancer patients is relatively limited, studies of sleep issues in the general population show that complementary therapies—particularly mind-body approaches—may be helpful, and these results are likely applicable to people with cancer.
Managing Sleep Problems with Mind-Body Therapies
Particularly because of the role that stress, anxiety, and other mental factors play in sleep issues, it is not surprising that complementary mind-body therapies may be of value. An analysis that pooled data from 59 studies, for example, found that psychological treatment averaging five hours of therapy meaningfully improved patients’ ability to fall asleep faster and stay asleep longer. Moreover, the benefits lasted for at least six months. Other studies support those positive results.
A National Institutes of Health consensus panel concluded that complementary techniques, particularly relaxation and biofeedback, improve some aspects of sleep. The magnitude of the improvements is somewhat less clear.13
Tai chi, a slow-moving, meditative form of exercise, may also benefit those with trouble sleeping. In one small randomized trial of older adults with moderate sleep complaints, subjects received either 16 weeks of tai chi classes or a general health education program. Those who practiced tai chi experienced a significant increase in sleep quality compared with their counterparts who took health education. Specifically, measures of sleep quality, efficiency, and duration were improved.14
In general, mind-body therapies are an appealing approach for various cancer symptoms because they are inexpensive, can be used along with medicines or other conventional approaches, can be practiced on one’s own after initial training, have virtually no side effects, and are safe.
Managing Sleep Problems with Exercise
Besides helping decrease fatigue, boost physical fitness, and even lower the risk of cancer recurrence, general physical activity has been shown to improve sleep. One clinical trial conducted in Taiwan found that an eight-week, home-based walking program significantly improved sleep quality in cancer patients. Additionally, patients who exercised experienced reduced levels of pain and improved quality of life.
Another trial of breast and prostate cancer patients receiving radiation treatment had similar results. After taking part in a four-week, home-based exercise program, patients reported greater sleep improvements than did those who did not exercise. In a separate clinical trial of breast cancer patients receiving hormonal treatment, women who participated in a walking program 20 minutes per day, four days per week, reported improved sleep quality within four weeks of starting the program.15
The list of favorable studies goes on and on. Given the well-known and evidence-based benefits of exercise for so many conditions, it’s a no-brainer. Whether it’s jogging, swimming, walking, or even gardening, you’ll benefit from being as active as your condition allows.
Yoga Improves Sleep Quality in Cancer Survivors
Cancer survivors who participated in a special yoga program reported better sleep quality and less reliance on sleep medication, according to the results of a study published in the Journal of Clinical Oncology.
In order to evaluate the impact of yoga on sleep, researchers conducted a randomized trial that included 410 cancer survivors with moderate to severe sleep disturbances that occurred two to 24 months after treatment. Participants were randomly assigned to standard care or standard care plus a 4-week yoga intervention called YOCAS® (Yoga for Cancer Survivors). The twice-weekly program included breathing exercises, 16 gentle yoga postures, and meditation.
Participants attended two 75-minute sessions per week for four weeks. Both groups showed improvement in overall sleep quality; however, the participants in the yoga group experienced greater improvement in sleep quality as well as sleep duration, sleep efficiency, sleep disturbances, subjective sleep quality, and daytime dysfunction.
They reported greater sleep quality, less use of drugs for sleep, less fatigue, and better quality of life. In fact, participants in the yoga group decreased their use of sleep medication by 21 percent, whereas those in the control group increased their use by 5 percent. The researchers concluded that yoga—and specifically the YOCAS program—could be a useful treatment for improving sleep quality and reducing the use of sleep medication among cancer survivors.17
What is Good Sleep Hygiene?
Sleep hygiene remains a potentially important part of a good night’s sleep.
Here are a few tips for sleep hygiene:
- Go to bed at the same time each night and wake up at the same time each morning.
- Make sure that your bedroom is quiet and dark.
- Use your bed only for sleep and intimacy.
- Avoid caffeine late in the day.
- Avoid alcohol before bedtime.
- Relax before bedtime—taking a warm bath, listening to calming music, or stretching may help you unwind.
- Avoid taking naps after 3 p.m., and when you do nap, do so for no more than an hour.
- Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13:307-349.
- Auld F, Maschauer EL, Morrison I, Skene DJ, Riha RL. Evidence for the efficacy of melatonin in the treatment of primary adult sleep disorders. Sleep Med Rev. 2017;34:10-22.
- Ferracioli-Oda E, Qawasmi A, Bloch MH. Meta-analysis: melatonin for the treatment of primary sleep disorders. PLoS One. 2013;8:e63773.
- Yurcheshen M, Seehus M, Pigeon W. Updates on nutraceutical sleep therapeutics and investigational research. Evid Based Complement Alternat Med. 2015;2015:105256.
- Hudson C, Hudson SP, Hecht T, Mackenzie J. Protein source tryptophan versus pharmaceutical grade tryptophan as an efficacious treatment for chronic insomnia. Nutr Neurosci. 2005;8:121-127.
- Therapeutic Research Center. Natural medicines. (Registration and login required.)
- Oxman AD, Flottorp S, Havelsrud K, et al. A televised, web-based randomized trial of an herbal remedy (valerian) for insomnia. PLoS One. 2007;2:e1040.
- Jacobs BP, Bent S, Tice JA, Blackwell T, Cummings SR. An internet-based randomized, placebo-controlled trial of kava and valerian for anxiety and insomnia. Medicine (Baltimore). 2005;84:197-207.
- Carlini EA, Cunha JM. Hypnotic and antiepileptic effects of cannabidiol. J Clin Pharmacol*.* 1981;21(S1):417S-427S.
- Linares IMP, Guimaraes FS, Eckeli A, et al. No acute effects of cannabidiol on the sleep-wake cycle of healthy subjects: a randomized, double-blind, placebo-controlled, crossover study. Front Pharmacol. 2018;9:315.
- Zick SM, Wright BD, Sen A, Arnedt JT. Preliminary examination of the efficacy and safety of a standardized chamomile extract for chronic primary insomnia: a randomized placebo-controlled pilot study. BMC Complement Altern Med. 2011;11:78.
- Lehrl S. Clinical efficacy of kava extract WS 1490 in sleep disturbances associated with anxiety disorders. Results of a multicenter, randomized, placebo-controlled, double-blind clinical trial. J Affect Disord. 2004;78:101-110.
- Integration of Behavioral and Relaxation Approaches into the Treatment of Chronic Pain and Insomnia. National Institutes of Health Technology Assessment Conference Statement. Available at: https://consensus.nih.gov/1995/1995behaviorrelaxpaininsomniata017html .htm. Accessed July 25, 2016.
- Irwin MR, Olmstead R, Motivala SJ. Improving sleep quality in older adults with moderate sleep complaints: A randomized controlled trial of tai chi chih. Sleep. 2008;31(7):1001–8. doi: PMC2491506.
- Rogers LQ, Hopkins-Price P, Vicari S, et al. Physical activity and health outcomes three months after completing a physical activity behavior change intervention: Persistent and delayed effects. Cancer Epidemiology, Biomarkers and Prevention. 2009;18(5):1410-8. doi: 10.1158/1055-9965.EPI-08-1045.
- 2019; doi:10.1002/cncr.32509
- Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. Journal of Clinical Oncology. Published early online August 12, 2013. doi: 10.1200/JCO.2012.43.7707
1. Idorsia’s new treatment Quviviq (daridorexant) is now available in the US for adults living with insomnia. News release. Idorsia Pharmaceuticals Ltd. Accessed May 2, 2022. https://www.globenewswire.com/news-release/2022/05/02/2433104/0/en/Idorsia-s-new-treatment-QUVIVIQ-daridorexant-is-now-available-in-the-US-for-adults-living-with-insomnia.html
Quviviq. Package insert. Idorsia Pharmaceuticals Ltd; 2021. Accessed January 10, 2022. https://www.idorsia.us/documents/us/label/Quviviq_PI.pdf
Barrie R. Cassileth, MS, PhD, is Laurance S. Rockefeller chair and chief of the Integrative Medicine Department at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City. She has an extensive medical leadership career and is a recognized authority on complementary therapies and integrative medicine in oncology. Her work includes more than 170 publications in medical literature, more than 40 medical textbook chapters, and 22 books for physicians, patients, and families. She was a founding member of the Advisory Council to the US National Institutes of Health Office of Alternative Medicine, now the National Center for Complementary and Alternative Medicine; she previously served on the National and NY-NJ Regional Boards of the American Cancer Society and on multiple national and international committees. She is a staunch opponent of cancer quackery. She is founding president of the Society for Integrative Oncology. Since joining MSKCC in 1999, Dr. Cassileth has established prototypic research, education, and clinical programs in integrative medicine. Her most recent book, Survivorship: Living Well during and after Cancer, an evidence-based guide for patients and families, was published in April 2014 by Spry.
Excerpted with permission from Survivorship: Living Well during and after Cancer (Spry Publishing, 2014; $16.95) by Barrie Cassileth, PhD. © Copyright 2014 Spry Publishing. Available for purchase everywhere books are sold.
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