According the Centers for Disease Control and Prevention, a third of the U.S. adults report that they usually get less than the recommended amount of sleep. Sleep deprivation is linked to many chronic diseases and conditions, including obesity, heart disease, type 2 diabetes, and depression.
For many cancer patients and survivors, insomnia, a sleep disorder characterized by difficulty falling asleep or staying asleep, can be a side effect of living with cancer. There are quite a few reasons as to why patients and survivors might have trouble with sleep. A cancer diagnosis itself and the anxiety it can bring can cause insomnia, as can the side effects of treatment or medications and fear of recurrence.
In this podcast, we talk to Eric Zhou, PhD, a sleep psychologist at Dana-Farber who has done many studies on insomnia. We discuss why humans need sleep, but perhaps most importantly, we discuss how cancer patients, survivors, and other listeners can take steps to get as much sleep as they need.
MEGAN: So, as I mentioned, sleep deprivation can cause some health problems. A question we often get is: [Can] a lack of sleep…increase your risk of cancer? So, let’s address this right off the bat. What is the current research on this?
ERIC ZHOU, PHD: So, what we do know is that there is a lot of good research to suggest that individuals who chronically don’t get enough sleep are at greater risk for a lot of different health effects, and these are serious health effects. This question about cancer is something that we don’t know enough about to say definitively. However, there is a lot of good information that has been published to show that individuals who have shift work, for example, are at greater risk for the development of cancer, and that’s another part of this sleep puzzle that is often ignored. It’s not just always about whether you get enough, but the quality of that sleep matters, and when you get that sleep matters as well.
MEGAN: And can you kind of elaborate on that in terms of what is good quality sleep and when is the ideal time to get sleep?
ZHOU: There’s not an easy answer to that for everybody. “Good quality sleep” is very subjective. So, there are some more objective measures that we think about for folks. For example, we know that most adults typically have a range in the duration of sleep that is appropriate for them, and that range could be anywhere between 6 and 9 hours, with a little bit of wiggle room on either end of that spectrum.
That question of quality depends on things like whether you struggle to fall asleep, whether you wake up throughout the night, whether you wake up earlier than you want, and that’s much squishier. There’s not a specific answer—for example, somebody who wakes up once a night for 15 minutes may be really bothered by that, whereas for somebody else, they may think that’s the best night of sleep they’ve ever gotten. So, there’s not a great answer to that, unfortunately for the listeners.
And in terms of what the right time for sleep is, that also varies. Some people have a preference for going to bed and waking up earlier, some are more in the middle, and some are a little bit later. A part of that is genetic—it’s something that’s called your chronotype—and a part of that is something that we learn because of the work that we do, for example.
The issue that I had raised earlier around shift work was that folks who are in shift work positions, particularly rotating shift work positions, are at greater risk for health effects because their bodies are not used to specific times since they may be rotating these shifts, and also our bodies are built for sunlight, and if you’re always working the 12 midnight to 8 a.m. shift, you don’t get a whole lot of exposure to light, and this disrupts a bunch of biological processes because that’s how we’re built.
MEGAN: So, kind of getting into insomnia, which I know you have a lot of experience in, can you kind of talk about the general symptoms of insomnia?
ZHOU: Insomnia disorder is different than just experiencing symptoms. Now, the disorder is something that I typically tell patients the threshold for actually being at that level is much lower than many of us expect.
So, insomnia is described by somebody who has difficulty with falling asleep, staying asleep, or waking up too early, and the bar is set at 30 minutes per night, meaning if, in total, it takes you 30 minutes or more per night to fall asleep, plus you’re awake in the middle of the night or you wake up early, you’ve exceeded that bar, if that occurs three nights a week or more for three or more months.
Now, to make that more tangible, think about somebody who takes 20 minutes to fall asleep at the beginning of the night and at the middle of the night is up for another 20 minutes. That doesn’t sound like a lot, but if they hit that threshold three nights a week, they’ve passed the bar that would meet diagnostic criteria for insomnia disorder.
Now, of course, this comes with other details, like, for example, this can’t be caused by, say, somebody who is drinking, somebody who just had surgery, that there’s another direct cause, and also this must cause daytime consequences. So, somebody who experiences these sleep disruptions, but they love their day and have no problems with it, wouldn’t meet diagnostic criteria, but certainly, in my clinical sense, I would say we should be revisiting that conversation with this person.
MEGAN: Can you kind of talk about what cancer patients report as the most common causes of insomnia—for example, some certain treatments or medications?
ZHOU: Yeah, there are a whole lot. Here at Dana-Farber, we do a wonderful job of prolonging life and saving the lives in many instances of our patients, but those lifesaving therapies—and I use the word “therapies” because there are many different ones that you are thinking of—can all cause sleep disruption. Some of the issues aren’t even caused by the treatments.
So, what we tend to think about in our sleep world are what are called “precipitating events.” So, these are the events that cause somebody’s sleep to go off the tracks, if you will, and here at the Farber, they could be from as early as going in for a scan before you even know you have cancer to being told that you have cancer.
And specifically to the treatments that you mentioned… So, for example, somebody who is in-patient at a hospital after a surgery or somebody who, say, has breast cancer and because of their treatment is in early menopause and experiences hot flashes, somebody who received radiation treatments and are very fatigued and may have to nap during the day, somebody who is on steroids, and that actually causes them to stay up at night, which makes them sleep the next day. All of these things are things that can precipitate or cause somebody’s insomnia to begin.
So, I think—and I know I’m a little biased because I think about sleep all of the time, but I like to think almost all of the patients who walk into the door here at this hospital are likely to have had at least one bad night of sleep during our care, and for many of our patients, because of the sequence of treatments that they get, it is many bad nights of sleep.
MEGAN: Generally, what are some practices you might recommend to anyone who is having trouble sleeping. I know we hear a lot, “Don’t look at your phone before you go to bed,” kind of stuff. Any kind of general practices?
ZHOU: Absolutely. If I can actually reframe that question a little bit… Before we think for individuals about general practices or tips or strategies to help with sleep, I think it’s important for people to understand exactly what the nature of their sleep issues are in the same way that we probably wouldn’t—well, not even probably—that we definitely wouldn’t treat somebody here without knowing exactly what kind of cancer they have.
Sleep is similar in the sense that we need to understand exactly what the disorder is before we actually intervene, and the reason I say this is, for many individuals, they also are struggling with other sleep disorders, not necessarily just insomnia. For example, a common sleep disorder is sleep apnea. That’s something that can absolutely cause somebody to have sleep disturbances overnight, and that is treated entirely separately from their insomnia.
So, first and foremost, I would say, is to make sure that a proper, thorough evaluation of this patient’s sleep is done. If that’s the case, and if we say that they have insomnia, there are absolutely things that they can do in order to improve their sleep.
The extent to which you would want to intervene depends on the extent of the problem. So, we’ve actually found in some of our research that for folks who I would say a little bit of bad sleepers—they’re not really at the point in which they have full-blown disorder, they’ve just kind of had some things that they need to clean up around the edges—what you might read about online, things like avoiding electronics use in the hour or two before bedtime, not watching TV in bed, not having caffeinated beverages later in the day… These are all things that I think clean up around the edges and can certainly help some individuals.
Unfortunately, we know from research as well that for individuals who truly have insomnia, these tips and strategies often don’t work. They’re just not enough, and in my clinic, I see a number of patients who say, “I’ve tried everything, I’ve done it all,” and what it really means is they’ve gone online and found this list of sleep hygiene tips and tried them all, and it didn’t really matter so much, and that’s not a surprise.
What we then do is we use an approach called “cognitive behavioral therapy for insomnia,” or CBTI. Now, CBTI is different than what many individuals think of as CBT. We’ve probably heard that term before in the context of therapy for things like depression, anxiety, PTSD, but it’s an entirely different approach for insomnia than it is for these other disorders. That’s what we would typically start working on with these patients.
MEGAN: OK, that makes a lot of sense. Are there any web resources you might suggest to anyone who is listening and kind of wants to learn more and dig in to, again, learn more about insomnia and other sleep-related issues?
ZHOU: Absolutely. There’s a lot of good information online as well as, you can imagine, a lot of not-so-good information, and I think that good resources for individuals who are interested in learning more about insomnia and what CBTI looks like, the [American] Academy of Sleep Medicine has a great amount of material, and the Society of Behavioral Sleep Medicine has great material to help people understand exactly what this kind of work looks like—and even when somebody may want to consider finding a provider to be able to do better with their sleep.
MEGAN: So, before I let you go, any kind of last words you might want to mention on this topic? Any research you’re working on that’s exciting to you? Anything in that vein?
ZHOU: Sure. I think the last message that I would want listeners to think about when it comes to sleep is—and I get this question asked a lot, which is, “If I could do one thing differently about my sleep, what would I do, or what should I do?” and I think the answer I would give to most individuals is to wake up at a consistent time every single day as opposed to going to bed at the same time every single day.
The reason for that is because we can’t consciously control when we fall asleep. You don’t have an on and off switch, and that’s often frustrating for people who have difficulty with sleep onset. They go to bed, they lay there, they toss, and they turn. They learn to be frustrated with sleep. However, if you flip this on its head and you actually change that to waking at the same time every single day, regardless of when you went to bed or when you fell asleep, what it does is it teaches you that if you didn’t sleep well the night before, but you wake up at the same time, what it does is it simply extends that sleep debt that you’ve just accumulated from that last night into tomorrow night so that tomorrow night’s sleep will hopefully be better than last night’s. And if you maintain this consistency moving forward, what you often see is there is less variability in how much sleep somebody gets on average and how they feel.
And in terms of the research that we’re doing, we’ve been working with a number of folks here in order to do things like deliver web-based treatment for our survivors, to do what is called the “Stepped Care Approach,” which means we use a very low-intensity approach as the first course of treatment, and if a patient still struggles with their insomnia, then we can wrap up the intensity or the dosage of the work.
We’re trying to find creative ways to be able to get this message out to our patients that we can help with sleep, the treatment doesn’t take forever, and, in fact, for most of our patients, we see that within three sessions they are already doing substantially better, and that there is absolutely a nonpharmacological treatment that can help with insomnia, which is important for our patients because they’re already on a lot of medications, and we also know that the American College of Physicians has advised that cognitive behavioral therapy for insomnia should be the first approach to treating insomnia.