Sleep Problems and Solutions

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Beyond Blue Survivorship Issue
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From the moment you’re diagnosed with colorectal cancer, simple life experiences or pleasures that once came so easily may begin to elude you. In addition to the life-changing diagnosis thrown your way, what may have once been something you had taken for granted can become a monumental issue – like getting a good night’s sleep. Sleep problems in people with colorectal cancer is a quality of life issue.

Sleep is crucial to healing. Maybe you didn’t sleep for weeks when you were first diagnosed. Perhaps you cruised through chemo and radiation and slept like a baby every night. Possibly, you had surgery, and now you need to get up numerous times throughout the night to use the bathroom. While your daily quality of life during daylight hours has already been negatively affected, now you find yourself with sleep problems: awake at night, unable to fall asleep or stay asleep.

It’s common for colorectal cancer patients, their families, and loved ones to lose sleep or have sleep problems – whether from treatment effects, or from stress, fear, or anxiety. Loss of sleep profoundly affects quality of life. It is difficult, if not impossible, to function optimally when you aren’t sleeping well. It’s beyond frustrating to be awake for hours at night, only to wake up groggy and barely able to get out of bed the next morning. 

Q&A with Sleep Tips from an Expert

Fight CRC spoke with Douglas E. Guggenheim, MD, a medical oncology specialist in the department of Hematology and Oncology at the University of Pennsylvania, about sleep problems in people with colorectal cancer.

Q: What are the first steps someone with cancer can take if they aren’t sleeping well? 

A: There have been lots of anecdotal conversations with regard to how to manage insomnia and sleep problems throughout the cancer continuum. The problem with insomnia is that it can be multifactorial, treatment related, social, or psychological in nature. With that, the approaches and strategies with which we must employ must first start with conversations regarding what triggers may be contributing to the specific sleeping issue. Probably the best strategy to begin assessing one’s sleep problems would be to start with a sleep diary, assessing and looking for specific trends that may be contributing. For example, medication used at a certain time of the day, such as the timing of steroids, or identifying fractured sleep hygiene in the sense that one’s schedule is very off with regard to a consistent bedtime or sleep routine. With regard to specific concerns about steroids, the general strategy is to take these medications early in the day to ease the side effects at bedtime. Typically, I would start with that approach and look to correct variations before escalating to other strategies. For example, a specific routine incorporating a set time for bed and a “winding down” process may help alleviate insomnia.

Q: What if those first steps don't help? Suppose cancer-related anxiety or depression is contributing to insomnia. 

A: Strategies for correcting sleep problems in people with colorectal cancer can certainly be considered at home by the patient or family looking for specific triggers. It is always important to include your physician as they can assist with a troubleshooting process and offer recommendations and options for next steps. There is evidence to suggest that one cause of insomnia could be stress and anxiety, and there may be a potential role for cognitive behavior therapy (CBT) from a talk therapy approach. 

Oftentimes, discussing one’s problems and concerns can relieve significant anxiety and assist a patient with developing tools with which they can address some of the specific concerns, leading to improved sleep hygiene. 

For a certain cohort of patients, support groups can assist with recommendations and strategies for improving sleep; however, from a more formal psychological perspective, literature supports the role of CBT as noted above.

Q: If those steps don’t address the sleep problems in people with colorectal cancer, what do you recommend next? What are your thoughts on complementary and alternative treatments?

A: If the above-noted strategies are not particularly helpful in alleviating sleep problems, employing alternate treatment strategies are appropriate – whether that be aromatherapy, acupuncture, nontraditional medication, and supplements, such as melatonin. These should be discussed with the treating physician or supportive care provider to provide the best potential recommendations.

The problem, however, is once the above-noted issues have been exhausted, where does one go? This is often when the physician thinks of a more pharmacologic approach to treatment. There are reasonable anecdotal experiences to suggest the role of medical marijuana and its derivatives to assist with insomnia; however, one could also consider antianxiety medication. Antidepressants or antianxiety medications, such as Xanax®, Zoloft®, and Lexapro®, may be helpful in supplementing serotonin and may alleviate some of the stress and distress related to colorectal cancer, leading to better sleep. There are also specific sleep-directed medication such as Ambien® or Lunesta® , which could also be helpful for patients struggling to achieve peaceful sleep at night. Typically the goal would be to exhaust treatment options with less potential side effects, as some of the more aggressive strategies can lead to dependence and addiction. If you are receiving palliative care, be sure to include your oncology team so they can help your palliative care team and you manage and maintain the best possible quality of life. 

Q: Finally, is there a point where a patient needs doctor-prescribed medicines or perhaps other legal alternatives to help with their sleep problems? 

A: It’s very clear that there can be many different contributing factors to sleep problems in people with colorectal cancer. Using a troubleshooting approach at first can yield very successful results; however, there are potentially many other strategies with which we can employ to improve causes and symptoms of insomnia. From my perspective, an “all hands on deck“ strategy in cooperation with a team approach with your physician yields the most successful results for patients working through the issues and challenges of treatment and recovery from cancer.

5 Tips for Managing Sleep Problems

Sometimes it’s good to return to concepts that may help ease yourself into sleep. When your mind is heavy with thoughts and anxiety over diagnosis, treatment, surgery, maintenance, and survivorship, life is busy and keeps moving forward at a frantic pace. Be sure to exhale, and work your way through the list of tips below. 

Create an optimal sleep environment.

Keep your bedroom cool, but not cold. It’s hard to sleep when your feet are freezing. You can lower your thermostat or use a ceiling fan. 

Get rid of distractions and step away from the blue light.

Charge electronics each night, but turn off notifications and sound. If you can’t turn off your electronics, put them on “Do Not Disturb” mode. Try to place them farther than arm’s reach, so you can avoid the temptation to pick them up if you awaken in the middle of the night. Your phone, table, and laptop all emit blue light, which stops melatonin production. Melatonin is key in getting you ready to fall asleep and can help prevent sleep issues.

Cut the caffeine and sugar.

Try to avoid all things caffeine and sugar after 6pm. Both caffeine and sugar interfere with your ability to fall asleep and may cause sleep issues. Some people believe alcohol helps them sleep better, and while it may make you feel ready to nod off, alcohol often causes your body to wake up, which may mean a restless night’s sleep. 

Rule out medical causes.

Joe Bullock, stage III survivor, found out he had sleep apnea while undergoing chemo. Bullock’s wife had asked him for years to do something about his snoring. Bullock didn’t take his sleep problems seriously until his oncologist one day said, “I’ve helped you survive cancer. I don’t want you to die of sleep apnea.” Bullock uses a continuous positive airway pressure (CPAP) machine, and his sleep problems have mostly resolved.

Find your peace, however that looks.

There are multiple ways that people find peace. Warm water can help your body and mind begin to destress as you wind down, so some prefer to take a warm bath or shower at night. Others may take deep breaths, meditate, or pray to help them feel at peace. Some people appreciate the essential oil lavender in a diffuser, lotion, or spray to bring them a natural calm. Whatever it is that helps you calm your mind and body, consider doing that to help prepare for bed. 

How Physical Activity Can Help You Sleep

If you have sleep issues, don’t get enough sleep, or a good night’s sleep, try to incorporate exercise, if possible, into your day. Daylight tells your body to wake up and get moving. Fresh air and activity are great ways to energize your body. According to the National Cancer Institute, benefits of exercise include:

  1. Improved sleep, which helps your body rest and recover.
  2. Boosted mental health, which may reduce anxiety and depression. 
  3. Decreased pain, since exercise helps relax your primary muscles.

Just be sure to get your light and movement early in the day rather than later at night. If you exercise earlier in the day, you can feel refreshed throughout your daily activities while also tiring yourself out enough to sleep well at night. Fresh air and activity are great ways to increase your energy, so try to make them both a consistent routine in your day.

There are clinical trials focused on sleep problems, including one that is currently enrolling for people undergoing treatment: Comparing Brief Behavioral Therapy (BBT-CI) and Healthy Eating Education Learning (HEAL) for Cancer-Related Sleep Problems While Receiving Chemotherapy

Finally, know that you are not alone. Be sure to speak with your medical team if you are struggling with sleep problems. Together, you can work to figure out a sleep solution that works for you. 

CRC Survivors’ Thoughts About Sleep

“Sleep has been so interesting through all of my treatment. During radiation and Folfox, I slept like a rock! When we added steroids to my second bout (recurrence in liver and lungs), I started getting my days and nights mixed up. Then we had to add meds to help with the sleep so for a little while I was sleeping ALL the time. Some sleep aids made my legs jump so we had to add in Ativan®, which caused it’s own issues. Now that I’m on hospice, I sleep often: good sleep at night and a nap or two during the day. It’s been a fight for the last almost six years … Sleepless nights are also really hard on my mental health. I have to distract myself with TV or a game on my phone to keep my thoughts from wandering.”

–Shiray Berry, stage IV survivor

“While I was undergoing chemo, I found out I had sleep apnea. I told my oncologist that I was having a hard time sleeping, and I snore. He sent me to a neurologist for a sleep study. I now have a CPAP that I use nightly, and I am sleeping much better.”

–Joe Bullock, stage III survivor

“I have horrible sleep issues, which go from not being able to sleep for weeks – to sleeping all the time.” 

–JJ Singleton, stage IV survivor

“Weed. It’s done wonders for my sleeping after I was having strange dreams that would wake me up, and then I would struggle to get back to sleep only to have the same theme of a dream all night long. I have been on chemo, and it started with my sleep being filled with anxiety about my life ending and leaving my wife alone. I knew the benefits of marijuana, so I asked my doctor if it was OK to pursue along with ancient herbal medicine. My doctor said ‘no’ to herbal medicine, but OK to marijuana. This was about three months into my treatment after diagnosis.”

Tim McDonald, stage IV survivor

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