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Sleep Disorders (PDQ®)

Sleep Disturbance in Cancer Patients

Cancer patients are at great risk for developing insomnia and disorders of the sleep-wake cycle. Insomnia is the most common sleep disturbance in this population and is most often secondary to physical and/or psychological factors related to cancer and/or cancer treatment.[1-5] Anxiety and depression, common psychological responses to the diagnosis of cancer, cancer treatment, and hospitalization, are highly correlated with insomnia.[6,7];[8][Level of evidence: II]

Sleep disturbances may be exacerbated by paraneoplastic syndromes associated with steroid production and by symptoms associated with tumor invasion, such as draining lesions, gastrointestinal (GI) and genitourinary (GU) alterations, pain, fever, cough, dyspnea, pruritus, and fatigue. Medications—including vitamins, corticosteroids, neuroleptics for nausea and vomiting, and sympathomimetics for the treatment of dyspnea—as well as other treatment factors can negatively impact sleep patterns.

Side effects of treatment that may affect the sleep-wake cycle include the following:[9];[8][Level of evidence: II]

  • Pain.
  • Anxiety.
  • Night sweats/hot flashes (refer to the PDQ summary on Hot Flashes and Night Sweats for more information).
  • GI disturbances (e.g., incontinence, diarrhea, constipation, or nausea).
  • GU disturbances (e.g., incontinence, retention, or GU irritation).
  • Respiratory disturbances.
  • Fatigue.

Sustained use of the following medications commonly used in the treatment of cancer can cause insomnia:

  • Sedatives and hypnotics (e.g., glutethimide, benzodiazepines, pentobarbital, chloral hydrate, secobarbital sodium, and amobarbital sodium).
  • Cancer chemotherapeutic agents (especially antimetabolites).
  • Anticonvulsants (e.g., phenytoin).
  • Adrenocorticotropin.
  • Oral contraceptives.
  • Monoamine oxidase inhibitors.
  • Methyldopa.
  • Propranolol.
  • Atenolol.
  • Alcohol.
  • Thyroid preparations.

In addition, withdrawal from the following substances may cause insomnia:

  • CNS depressants (e.g., barbiturates, opioids, glutethimide, chloral hydrate, methaqualone, ethchlorvynol, alcohol, and over-the-counter and prescription antihistamine sedatives).
  • Benzodiazepines.
  • Major tranquilizers.
  • Tricyclic and monamine oxidase inhibitor antidepressants.
  • Illicit drugs (e.g., marijuana, cocaine, phencyclidine, and opioids).

Hypnotics can interfere with rapid eye movement (REM) sleep, resulting in increased irritability, apathy, and diminished mental alertness. Abrupt withdrawal of hypnotics and sedatives may lead to symptoms such as nervousness, jitteriness, seizures, and REM rebound. REM rebound has been defined as a marked increase in REM sleep with increased frequency and intensity of dreaming, including nightmares.[10] The increased physiologic arousal that occurs during REM rebound may be dangerous for patients with peptic ulcers or a history of cardiovascular problems. Newer medications for insomnia have reduced adverse effects.[11]

The sleep of hospitalized patients is likely to be frequently interrupted by treatment schedules, hospital routines, and roommates, which singularly or collectively alter the sleep-wake cycle. Other factors influencing sleep-wake cycles in the hospital setting include patient age, comfort, pain, and anxiety; and environmental noise and temperature.[12]

Consequences of sleep disturbances can influence outcomes of therapeutic and supportive care measures.[13] The patient with mild to moderate sleep disturbances may experience irritability and inability to concentrate, which may in turn affect the patient's compliance with treatment protocols, ability to make decisions, and relationships with significant others. Depression and anxiety can also be caused by sleep disturbances. Supportive care measures are directed toward promoting quality of life and adequate rest.

References

  1. Savard J, Morin CM: Insomnia in the context of cancer: a review of a neglected problem. J Clin Oncol 19 (3): 895-908, 2001. [PUBMED Abstract]
  2. Savard J, Simard S, Blanchet J, et al.: Prevalence, clinical characteristics, and risk factors for insomnia in the context of breast cancer. Sleep 24 (5): 583-90, 2001. [PUBMED Abstract]
  3. Savard J, Simard S, Hervouet S, et al.: Insomnia in men treated with radical prostatectomy for prostate cancer. Psychooncology 14 (2): 147-56, 2005. [PUBMED Abstract]
  4. Otte JL, Carpenter JS, Russell KM, et al.: Prevalence, severity, and correlates of sleep-wake disturbances in long-term breast cancer survivors. J Pain Symptom Manage 39 (3): 535-47, 2010. [PUBMED Abstract]
  5. Lee ES, Lee MK, Kim SH, et al.: Health-related quality of life in survivors with breast cancer 1 year after diagnosis compared with the general population: a prospective cohort study. Ann Surg 253 (1): 101-8, 2011. [PUBMED Abstract]
  6. Bardwell WA, Profant J, Casden DR, et al.: The relative importance of specific risk factors for insomnia in women treated for early-stage breast cancer. Psychooncology 17 (1): 9-18, 2008. [PUBMED Abstract]
  7. Palesh OG, Roscoe JA, Mustian KM, et al.: Prevalence, demographics, and psychological associations of sleep disruption in patients with cancer: University of Rochester Cancer Center-Community Clinical Oncology Program. J Clin Oncol 28 (2): 292-8, 2010. [PUBMED Abstract]
  8. Van Onselen C, Cooper BA, Lee K, et al.: Identification of distinct subgroups of breast cancer patients based on self-reported changes in sleep disturbance. Support Care Cancer 20 (10): 2611-9, 2012. [PUBMED Abstract]
  9. Vena C, Parker K, Cunningham M, et al.: Sleep-wake disturbances in people with cancer part I: an overview of sleep, sleep regulation, and effects of disease and treatment. Oncol Nurs Forum 31 (4): 735-46, 2004. [PUBMED Abstract]
  10. Chouinard G: Issues in the clinical use of benzodiazepines: potency, withdrawal, and rebound. J Clin Psychiatry 65 (Suppl 5): 7-12, 2004. [PUBMED Abstract]
  11. Barbera J, Shapiro C: Benefit-risk assessment of zaleplon in the treatment of insomnia. Drug Saf 28 (4): 301-18, 2005. [PUBMED Abstract]
  12. Boonstra L, Harden K, Jarvis S, et al.: Sleep disturbance in hospitalized recipients of stem cell transplantation. Clin J Oncol Nurs 15 (3): 271-6, 2011. [PUBMED Abstract]
  13. Sateia MJ, Doghramji K, Hauri PJ, et al.: Evaluation of chronic insomnia. An American Academy of Sleep Medicine review. Sleep 23 (2): 243-308, 2000. [PUBMED Abstract]
  • Updated: April 23, 2014