Now that the goal of Christmas has been and gone, we lie in that week of the year to reflect and plan. Plan for the year ahead.

So imagine if you were told today that you had 5 months to live - what would you do?

I imagine most people would bring out their bucket list and see how many things they could do. However, there is a flaw in such a plan. It assumes that one will have the energy during the day to cross something off their bucket list.

Cancer has risen to be one of human’s greatest enemies. Not only does it directly rob us of our energy to do what we want during the day - but it also does this indirectly.

Via sleep.

From the grief of receiving the news; to the effect of cancer treatments; to the nighttime pain and frequent awakenings - it is no wonder that the peace that sleep provides is disrupted due to cancer.

This week’s blog will delve into the link between cancer and sleep - with a focus on how therapy can improve nighttime sleep and daytime fatigue.

This is not going to be a blog where people who stumble upon this post get a limited amount of info - subscribers get a bit more - and members get the whole lot. Today we’re putting as much science-backed info into the one place. In a concise a manner as possible.

It is likely that if we, ourselves, manage to avoid cancer, we will nevertheless know someone who will be struck by cancer - even struck down.

This year I was told that I have pre-cancerous cells forming on the right side of my face. I was at risk for this as I was born with a genetic skin condition - psoarisis - and I learned in my teens and 20s that baking in the Australian sun and lying in solariums controlled the psoarisis. But these behaviours clearly increase the risk of skin cancers (An et al., 2021).

So in my 40s I’ve paid greater attention to the research for other risk factors.

I’ve never smoked … cigarettes ;)

The research clearly shows alcohol is implicated in several cancers - especially in women (I’m not a woman, but I’m currently 3 years alcohol free; Choi et al., 2018; WHO, 2018).

And in a couple of days I would’ve completed a 365-day experiment to stop eating red meat (as this is also linked to cancers; Farvid et al., 2021).

To this end, I dedicate this blog to our family’s Uncle Phil from Wales - a healthy, fit, kind and proud Welshman, who within a couple of months, passed away in June this year due to an aggressive form of lymphatic cancer.

Uncle Phil taught us something about how to live - each and every day …

F#ck cancer …

Whilst sleep problems are now common amongst the population, they are 2 to 3 times more common in people diagnosed with cancer (eg, Ancoli-Israel, 2015).

The severity of such sleep problems sit within the moderate-to-severe range for about 2 in every 3 people with cancer.

Interestingly, in Sonia Ancoli-Israel’s 2015 review, she reports that many people with cancer report the onset of sleep problems prior to their diagnosis of cancer - suggesting that ‘insomnia symptoms’ may be a red flag amongst other pre-diagnostic symptoms.

Think about that. We are often told to see our doctor if we experience symptoms related to different forms of cancer - however, maybe we should pay more attention if insomnia accompanies such pre-diagnostic symptoms?

The types of sleep problems can vary.

There can be difficulty falling asleep, waking frequently (and for long periods of time) during the night, disruptions in people’s circadian rhythms, and naturally a lack of energy and motivation to do things during the day.

Research into treatments for sleep problems (we may as well say insomnia from now on) have been conducted since the 1990s.

And the collective evidence shows insomnia therapies are effective (van der Zweerde et al., 2019).

The key question is - whether having insomnia due to cancer (or its treatment) renders such insomnia therapies ineffective?

Getting Closer to the Peace of Sleep

Usually when a co-morbid mental or physical health problem is treated, then the associated sleep issue lessens. This however is the opposite that occurs when cancer is the co-morbid condition.

During chemotherapy and radiotherapy, there is an exacerbation of sleep problems, which may decrease by the completion of therapy - but are unlikely to disappear. In contrast, when surgical intervention is the focus of treatment, insomnia and sleep problems can significantly decline.

The most studied sleep therapy for those experiencing insomnia and cancer is Cognitive-Behaviour Therapy for Insomnia … also known as CBT-I.

For example, there have been 14 high quality trials that have assessed the effect of CBT-I on women experiencing both insomnia and breast cancer (Ma et al., 2021).

CBT-I was effective at reducing insomnia symptoms by the end of treatment.

In 8 out of the 14 trials, CBT-I was even compared to other forms of intervention, such as mindfulness-based stress reduction, exercise, healthy eating and Tai Chi) - but CBT-I was superior to these.

Even after 6 or 12 months having ceased CBT-I, patients’ insomnia was better than before they learned the skills to improve their sleep - albeit their sleep was still far from perfect.

This brings us to the concept of ‘cancer survivors’. People who have managed to beat cancer!

In a meta-study of 752 cancer survivors (Johnson et al., 2016), CBT-I reduced the time taken to fall asleep by 22 min, and the time spent awake during the night by 30 min.

These are meaningful improvements, and bring those experiencing - and who have even beaten cancer - closer to a peaceful night.

But what about their energetic days?

Holding the Door on Fatigue

Fatigue is one of the highest daytime symptoms reported by those experiencing insomnia - and in many cases, fatigue is the primary reason some people with insomnia seek treatment (Gradisar et al., 2007).

Fatigue is a massive problem when it comes to cancer.

Not only is fatigue heightened prior to cancer treatment - but it is exacerbated by the end of treatment (eg, chemotherapy).

Fortunately, fatigue can significantly decrease well after chemotherapy has ceased (eg, 1 year), but the severity of the fatigue is still higher than that experienced than people without cancer.

Fortunately, some studies have showed that CBT-I can not only improve sleep but also the associated daytime fatigue (Dirksen & Epstein, 2008; Fleming et al., 2014; Ritterband et al., 2011).

One research group found that the improvements in daytime fatigue were related to reductions in the severity of patients’ insomnia (Heckler et al., 2016).

Most forms of CBT-I do not address possible disruptions of circadian rhythms (ie, the timing of one’s biological clock - and thus the timing of one’s sleep pattern).

As demonstrated in our online course for teenagers, bright light therapy and melatonin are effective treatments to improve the timing of one’s body clock - and hence, sleep patterns.

Interestingly, light therapy has been shown to improve cancer patients’ levels of fatigue.

For instance, morning light therapy prevents the known increase in fatigue during chemotherapy (Ancoli-Israel et al., 2012), and decrease daytime fatigue in cancer survivors (Johnson et al., 2018).

Thus - on top of the improvements that may be found with CBT for Insomnia - morning bright light may provide an added way to manage cancer-related fatigue.

Conclusions?

There are a couple of movies that have a line in them that tear at my heartstrings. One is in the Lord of the Rings: Fellowship of the Ring, when Gandalf the Grey says:

“All we have to decide is what to do with the time that is given us.”

We approach the end of another year, and are about to be bombarded about how we can make New Year’s Resolutions stick. Possibly even how we should make sleep a priority.

But maybe we need to think of Gandalf’s statement? Simplify things?

Maybe we need to wake up each morning from hereon in, and do what we were born to do.

Live. And enjoy every day.

• Prof MG