It isn't hard to understand why many people with cancer have difficulty sleeping at one time or another. First, there is the shock and upset of diagnosis, and having one's world upended. Next, there is worry about treatment and its side effects…will it work? Will I live? And, of course, there is concern about the impact of cancer on family and friends…on work…on the unknowable future.

But sleep is important in managing treatment, its side effects, and having a reasonable quality of life. So it is essential to understand the reasons for sleeping problems, and to take steps to correct them, just as you would for any other side effect of cancer and cancer treatment. The fact that the presence of some sleep problems may be "normal" for a person with cancer does not mean that the problem should be ignored or dismissed as unimportant. Once sleep problems occur more than a few times, mention this to your health care team and get help in finding effective ways to manage this side effect.

Other major causes of sleep problems, in addition to anxiety issues mentioned above, include:

• Pain
  
  
• Side effects of medications (some cause wakefulness)
  
  
  
  • Corticosteroids (prednisone, dexamethasone) can make people feel hyperalert, tense and anxious. Taking this medication in the morning, rather than in divided doses throughout the day, can reduce the effect on sleep.
    
  • Some medications that control nausea can contribute to wakefulness — notably prochlorperzine (Compazine) and clopramide (Reglan).
  
  
• Night sweats/hot flashes — some cancer surgery and medications can trigger these. "Instant" menopause, with resulting hot flashes, can result in women because of cancer surgeries and chemotherapy.
  
  
• Depression
  
  
• Being hospitalized — where noise, roommates, treatment schedules can all interfere with rest

Symptoms

The most common symptoms of sleep problems include:

• Insomnia (difficulty falling and staying asleep)
  
• Difficulty concentrating and remembering
  
• Early morning awakenings, without the ability to return to sleep
  
• Excessive fatigue/sleepiness

Prevention & Coping

While it may not be possible to prevent sleep problems entirely, there are some useful tactics and techniques that are recommended by survivors and health care providers:

• Make your bed a place where you go to sleep — rather than making it also a place for other activities like watching television, talking on the phone, reading and eating.
  
  
• Make your bedroom a place that encourages sleep, with little or no light, quiet, the right sleeping temperature for you, clean bedding, and comfortable pillows.
  
  
• Make an effort to set a regular time each day for sleeping and waking. A routine seems to make it easier to fall asleep on schedule.
  
  
• Don't eat large meals before trying to sleep — although some people find a protein-based snack two hours before sleep is helpful.
  
  
• Caffeine can keep you awake, so avoid drinks with caffeine, such as coffee, tea and soft drinks during the afternoon and evening.
  
  
• Alcohol, while it might make you sleepy initially, also can keep you awake at night. If possible, avoid alcohol.
  
  
• Make sure your health care team knows all medications you take, including over-the-counter drugs. Since medication is so much a part of cancer treatment, your team needs to know what else you use, to make certain to avoid drug-drug interactions that can contribute to sleep problems. Ask if medications can be given on a schedule that won't interrupt sleep.
  
  
• If possible, avoid napping during the day. If naps are essential to combat fatigue, make them brief, no longer than 20-30 minutes or so. Don't nap in late afternoon or early evening. Prolonged napping makes it difficult to sleep at night.
  
  
• Avoid lying in bed for a long time unable to sleep. Try spending no more than about 15 minutes in bed trying to sleep; if sleep doesn't come, get up and go into another room and remain there until you feel sleepy, then return to bed.
  
  
• While exercising during the day will help you sleep at night, exercise within two hours of trying to sleep can help keep you awake and should be avoided.
  
  
• If you must be hospitalized, be aware that hospitals aren't always a good place to sleep soundly — especially if you have a roommate. The noise, lights, conversations, treatment and medication interruptions all conspire against sleep. Plan ahead, and consider bringing along ear plugs, a sleeping mask, a tape recorder and tapes of music you can enjoy through a headset, a favored pillow…whatever makes you relaxed and comfortable.

Treatment

In addition to the techniques described above, there are procedures and treatments that your health care team may recommend to help you sleep. Let your care providers know you are not sleeping well, and request that they assist you in treating this side effect.

Your doctor will first talk with you about your insomnia, and then do a physical examination. He or she may sometimes use a polysomnogram, a device that measures brain waves, eye movements, breathing, and so forth while you sleep. This can help provide a picture of what's happening when you try to sleep.

• Medications may be recommended. This may take some trial-and-error before determining which medication works best for you. Your health care team will factor in management of your other side effects, other treatment issues and make recommendations tailored for your needs. Some antihistamines, antidepressants and others — are also effective. If these are right for you, your health care team will recommend them.
  
• Relaxation techniques prove helpful for some people — including relaxation therapy, biofeedback, hypnosis, imagery and meditation.
  
  
• You've heard it before — and that's possibly because it can be effective — some warmed milk or herb tea before bed (nothing with caffeine, of course) proves helpful to some people seeking sleep.
  
  
• Melatonin — a natural hormone produced in the body — has helped some people manage sleep problems. Please consult with your health care team before trying melatonin.

Don't take over-the-counter sleep aids without talking with your health care providers. These medications can and do interact with other medicines you may be taking.

Questions for Your Doctor

In treating sleep problems, your health care team may include an internist, oncologist and nurse.

1. I've been having trouble sleeping for some time. What recommendations do you have to help me with this problem?
   
   
2. Is medication appropriate? If so, which one(s)? And why do you think this is the best choice?
   
   
3. Can someone speak with me about the use of relaxation therapies?
   
   
4. Should I try an over-the-counter sleep medication? Are there any side effects?
   
   
5. Are there herbal and natural remedies I might try for help with insomnia?
   
   
6. How long will my sleep problems likely to continue?
   
   
7. Are there any other approaches to solving this problem than those we've already tried?

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