Rami A. Sela, PhD

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.

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Oncology researchers examine sleep issues in cancer patients and propose ways to increase quality sleep.

Rami A. Sela, PhD

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