We have all heard how important sleep is for our health. The stress of a cancer diagnosis and treatment on the body and mind can make sleep more difficult, yet it is important for healing. Even people whose treatment has ended commonly have trouble sleeping occasionally. For some of us, sleep can be a struggle.

While sleep can be difficult for anyone, it is almost twice as common in people who have been diagnosed with cancer. More than half of those ever diagnosed with breast cancer report having sleep problems, even years after ending treatment. In the Pathways Breast Cancer Survivorship Study, more than 9 years after a diagnosis, about half of study participants reported having trouble getting to sleep and 61% reported waking in the middle of the night or early morning.

How Much is Enough?

Experts say we need an average of 7-9 hours of sleep a night. About one third (33%) of us do not regularly get 7 hours of sleep, and it is almost half for Native Hawaiian/Pacific Islander, Black and Multiracial Americans. We need enough sleep to:

• Remember things and think clearly
• Clean out our brain (the glial lymphatic or glymphatic system) 
• Grow and repair cells
• Rebuild energy

Routinely getting less than 7 hours of sleep can cause health problems, such as:

• Overweight and obesity
• Heart disease
• Diabetes and poor blood sugar control
• Depression (which can also cause sleep problems!)

Then again, some studies show that sleeping 9 or more hours a night can be associated with some of those same health problems.

So, what is the answer? Dr. Mia Zaharna of Kaiser Permanente San Jose’s Sleep Medicine Laboratory says that some of us are “short sleepers” and some are “long sleepers” because of our genes. Everyone has their own sleep needs, and they can change over time; the important thing is to feel rested during the day.

Therese, Martha and Margarita, three participants of the Pathways Breast Cancer Survivorship Study told us about their sleep after a breast cancer diagnosis. The first two don’t do well the next day if they get less than 7-8 hours of sleep and are “grouchy” and “draggy.” Margarita was fine with getting 6 hours a night in the past, but now finds it much harder to function.

Sleep Problems

Getting a good night’s sleep is often hard during cancer treatment and can pose a problem for life for some survivors. Dr. Zaharna notes that it’s normal to wake up on occasion. If you feel well-rested and are not awake for long periods of time in the middle of the night, it probably isn’t a problem. Being tired during the day may be a sign that we aren’t sleeping well.

Both trouble getting to sleep and waking up can be long-term side effects of cancer treatment. Almost one in four (23%) of Pathways study respondents said their sleep was disturbed by pain, like the nerve problems reported in our Neuropathy Factsheet. Another one in five (20%) said feeling too hot disturbed their sleep; hot flashes or night sweats may be caused by surgical or “normal” menopause, or by tamoxifen, a common breast cancer hormonal therapy. Although there wasn’t a question about anxiety, worry or stress, about 2% of participants brought up that it troubled their sleep.

Stress commonly keeps people from getting to sleep or getting back to sleep. After being diagnosed with breast cancer, Therese had trouble getting to sleep because of anxiety. However, after the treatment ended, she rated her sleep as pretty good.

Our immune systems ramp up to fight cancer and in response to treatments. And it doesn’t just shut off after treatment. Ongoing inflammation sends a message to our brains that can disturb our energy, memory and thinking, mood, and sleep. For some, it could lead to insomnia (chronic trouble falling or staying asleep).

Martha was a “great sleeper” before her breast cancer diagnosis, but that changed; “I can honestly say there hasn’t been a night that I’ve slept uninterrupted since then.” She wakes up once or twice every night. Early on, she had anxiety, and she does have a stressful role at work, yet she also wonders if it became a learned behavior or pattern and “once I woke up, my mind was on.”

Our bodies have an internal clock to keep us on schedule, including our sleep. The main “body clock” is in the brain controlling hormones, like melatonin, which makes us sleepy. Margarita is a “night owl.” She often doesn’t get home from her Mexican folk dance classes until 11pm or midnight and goes to bed at 12 or 1am most nights. “On weekends it feels good to stay in bed,” she said, although “if I sleep too much, I also feel tired.” For a time, after her cancer treatment, Margarita had trouble waking in the morning, sleeping through her alarm clock for two or even three hours. Fortunately, her supervisor allowed her to adjust her schedule.

Tips for Better Sleep

Sticking to a regular bedtime and wake-up time is good for the body clock. Our body clock is directly linked to our eyes, so light matters! We can:

• Get sunlight during the day
• Avoid blue light (from phones, computers and TV) for 30-60 minutes before sleep
• Keep the bedroom dark and cool
• Use a face mask or blackout curtains to block out light
• If it isn’t quiet, try earplugs, create white noise with a fan, or play nature sounds

Being physically active during the day helped Therese with her sleep during treatment and it still helps now. If she doesn’t get enough sleep, she said “it affects not only my triathlon training, but my ability to function overall.”

Avoid eating or drinking later at night, and it is useful to limit coffee, tea and other drinks with caffeine in the afternoon and evening. As we get older, we may need to get up to use the bathroom more often during the night. You can find more tips about sleep here. 

If you have trouble getting to sleep, do something relaxing before bedtime, like taking a warm bath. Therese started having trouble getting to sleep again last year. She now has a ritual to help signal to her body that it is time to sleep, including writing about her day in a journal to “clear things out” of her mind and snuggling with her dog. And she uses an app to meditate almost every night. There are many apps to help guide deep breathing, meditation, or yoga, or help us to fall asleep. A few, like Insight Timer, are free. This list of apps to help with sleep offer a wide range of options:

• Calm music
• Nature or city sounds
• Stories (for all ages)
• Guided imagery
• Body scans to relax muscles
• Sleep tracking
• Journaling

For those who wake up, it may be enough to get up, go to the bathroom, drink some water, and lay back down. If not, experts often recommend staying in bed awake no more than 15-20 minutes. If by then you can’t sleep, try getting up and doing something quiet and calming, like reading a book (although it is best if it is a boring book). Avoid looking at your phone.

Martha tried many things over the years to quiet her mind and get back to sleep. Finally, in the past year, she found that sleep stories, also on an app, work for her. “It forces your mind to concentrate on the story, and there’s no room in the brain to think of other things.” Some nights she will wake again, listen to a second story and can still get a good night’s sleep!

For Therese, it is rare to have trouble going back to sleep; when she does, she will go back to the app for another meditation or read for a bit. For more tips check this out. 

When you’re working to improve your sleep try one thing at a time and keep notes to see what helps you sleep better.

If you still have trouble after trying these healthy sleep habits, ask your health care provider about help, such as light therapy or cognitive behavioral therapy (CBT). If you experience fatigue, and especially if you snore, you might want to talk to your doctor about sleep apnea. Sleep apnea is a common condition where you stop breathing for 10 seconds or longer during sleep.

Rest well!