If you have trouble sleeping, some new interventions may help.
By Patricia McAdams
Lorraine Chase, 68, of Poway, California, has “really lumpy breasts,” she says, which is probably why her large 6-centimeter (2.4-inch) tumor remained hidden for so long. Horrified when she finally found it in March 2005, she saw a surgeon immediately.

“Take off my breast,” she pleaded, nearly hysterical. “Take it off!”

Instead, her surgeon at the University of California, San Diego (UCSD) tested the tumor, labeled it estrogen-positive, and told Lorraine about an exciting new drug that might shrink the tumor. If it worked, her lump could simply be removed-instead of her breast. All she had to do was wait. And wait. And wait.

“I was so frightened I couldn’t sleep,” says Lorraine.

Why Can’t We Sleep?
Women are especially susceptible to sleep disorders, says Sonia Ancoli-Israel, PhD, professor of psychiatry at UCSD School of Medicine, former president of the Sleep Research Society, and one of the nation’s preeminent experts in the field of sleep disorders. There are some theories that women are more aware of their feelings than men, so they are more likely to report them. Insomnia also may be hormone related. And some cancers-such as ovarian cancer and breast cancer-may plunge even young women into premature menopause, so they may be coping with wearisome hot flashes and night sweats on top of everything else.

According to the National Sleep Foundation’s 2007 Sleep in America poll, 67 percent of American women say they frequently experience a sleep problem. The precise reason for sleep disturbances, however, remains a mystery, says Dr. Ancoli-Israel. For cancer survivors undergoing chemotherapy, she suspects that insomnia is linked to changes in one’s circadian rhythm.

“Some of these women are so fatigued that they are staying indoors and not getting enough light exposure during the day,” she says, referring to the fascinating link between light and a good night’s sleep. It sounds counterintuitive, but the more exercise you can get during the day, the better you sleep at night. Going for a walk, for example, and trying to get as much light exposure as possible, may be very helpful.

“I say that with all due respect, knowing that being active might be very difficult,” says Dr. Ancoli-Israel. “But if you can’t be active the day after chemotherapy, perhaps the day after that you can try to get outside.”

Curiously, Dr. Ancoli-Israel noticed that women often complain of insomnia before they start treatment for breast cancer. This raises some interesting questions that she hopes to answer in future studies. For example, should we treat the insomnia in the interval immediately after diagnosis but before chemotherapy begins? What effect might this treatment have on a patient’s outcome?

Behavioral Strategies

Daytime sleepiness reduces the quality of life for millions of women each year, leaving them stressed out, late for work, too tired for sex, and with little time for friends.1,3 Dr. Ancoli-Israel believes that behavioral modification based on good sleep hygiene is best when you cannot sleep and recommends trying a number of proven behavioral strategies for treating insomnia first.4

Research on a number of complementary approaches show promise as well. Among these, some small studies suggest that yoga may lessen insomnia.5 More promising, however, is light therapy.6 Dr. Ancoli-Israel is halfway through a clinical trial using full-spectrum light boxes by Litebook in treating newly diagnosed women. She is following them through the first four cycles of chemotherapy.

“These are very preliminary data, but so far it looks like bright-light treatment in the morning is improving sleep and decreasing fatigue for women with breast cancer.”

By far the most exciting treatment for sleep disorders in all patients-including those with cancer-is cognitive behavior therapy (CBT).7, , According to Dr. Ancoli-Israel, the 2005 National Institutes of Health Conference on Insomnia concluded that CBT is the safest and most effective treatment we have for insomnia.10

“Cognitive behavior therapy is a flexible treatment, tailored to the needs of a specific patient,” says Dr. Ancoli-Israel. “It focuses on behavioral and psychologic skills that foster better sleep and lower anxiety. Many cancer patients with insomnia may be hesitant to use drugs for their sleep treatment because they are already overwhelmed by the chemical and pharmacologic treatments they are prescribed for the cancer. Thus CBT may become the treatment of choice for insomnia in these patients.”7

Lorraine’s Story

Clearly, CBT became the treatment of choice for Lorraine Chase. Her large tumor responded to the new drug, and in November 2005 her surgeon was able to remove the cancer, leaving scarcely a trace of the surgery, Lorraine says, still amazed. Despite her great outcome, however, her sleep habits were “a total mess” during the seven months she waited for surgery, and they never returned to normal.

In 2007 Lorraine heard about a CBT study conducted by Lavinia Fiorentino, PhD, in Dr. Ancoli-Israel’s laboratory, and she decided to try it. At that point Lorraine was in bed about 10 hours a night, sleeping only six. By the end of her 12-week course, she was in bed about eight hours a night, sleeping most of that time. Although there were countless practical suggestions to help her sleep better, one in particular hit home: she was never to read, watch TV, or even worry in bed.

Lorraine has ongoing arguments with her mind, she says, laughing. “If my mind is wandering and worrying and carrying on for more than 15 minutes, I get up and go sit somewhere. I say [to my mind], Okay then, fine. Wander and worry and carry on, but you’re not doing it in bed.’

“But the mind really doesn’t like that, and it argues back and says, ‘No, I want to lie here in this comfy bed and worry.’

“‘No, you are going to sit up and do it.’

“After a while, though, you form good habits, and it’s like, Oh, boy, I’m in bed and I’m going to sleep!

Lorraine likes CBT because this therapy is healthier, long term, and-especially-under her control. “I really liked that it was under my control,” she says. “I would recommend this therapy to anyone who is willing to work a little for good health.”

Finding a Therapist

To identify a sleep therapist near you, you can visit the National Sleep Foundation Web site.11 You might also find a therapist through the Academy of Cognitive Therapy.12 Many therapists are generalists and may be able to treat insomnia. If you wish to try cognitive behavior therapy, ask if there is a psychologist on staff, or in town, who might be trained in this specialty.

Because CBT is so new, there are still too few therapists trained in this field. If you are unable to locate anyone near your home, you might consider, a Web-based company dedicated to helping improve the quality of people’s lives; it is funded and supported by grants from the National Institute of Mental Health and the Department of Health and Human Services of the National Institutes of Health.13 This program is headed by Academy of Cognitive Therapy clinical psychologist Richard Bedrosian, PhD, affiliate in psychiatry, University of Massachusetts Medical School. Dr. Bedrosian was personally trained and supervised by Aaron T. Beck, MD, the world-renowned psychiatrist from the University of Pennsylvania, known and revered as the “father of cognitive therapy.”14 The services of this group include a six-week treatment program to conquer insomnia.

Treating the Problem
The important point, says Dr. Ancoli-Israel, is to get your insomnia treated, if possible with behavioral therapies. She acknowledges, however, that sometimes medication may offer a more immediate effect. If you need to take a sleeping pill, she says, work with your physician to match the characteristics of a drug with your personal complaints. Some drugs are recommended for people who have difficulty falling asleep; others are best for those who need help staying asleep. Always talk with your physician about any medication or herbal remedy you may be considering, to be sure it will not interact with other drugs you may be taking.

Getting Some Shut-eye

Getting a good night’s sleep is very important. If you are not sleeping, says Dr. Ancoli-Israel, there are many things you can do to change the unhealthy patterns you have created.15, “Anything that helps you is a good thing to do, as long as it is not harmful. Yoga, for example, is certainly an excellent form of exercise, and exercise is always good. You need to start some behavioral therapy for long-term benefit, but maybe use a sleeping pill with the behavioral therapy for immediate benefit.”

You are likely to sleep better if you get rid of your bedside clock, suggests Dr. Ancoli-Israel. The presence of a clock sets you up to be tense and aggravated about not sleeping. If you wake up in the middle of the night, for example, you have to open your eyes, turn your head, and maybe even lift it to see that it is only 1:20 a.m. and you want to be asleep.

“What you’ve done is taken yourself from transitional sleep to full awakening, and now it’s difficult to fall asleep again. The best thing to do is get rid of the clock so you are not tempted to look.”

Finally, Dr. Ancoli-Israel suggests that you schedule 15 to 20 minutes-the same time every day-to sit and worry. “The first moment we have to think in our busy lives is when we get into bed at night. That is the wrong time to start thinking. Set aside a ‘worry time’ instead. What that does is free you up from thinking about your problems at night. It sounds silly,” she says, “but it’s very effective.

“Again, talk with your physician about your sleep,” she advises. “Many women feel sleep is not the most important thing right now. It is important to talk about sleep deprivation, however, along with any other symptoms you may be experiencing. All of those things will play into your quality of life and your ability to function.”

Tips to Help You Sleep

  • Exercise is very important-whatever you are able to do.
  • Get exposure to bright light during the day. Remember, sunshine is the brightest light we have. (Remember to cover up and use sunscreen.)
  • Keep your nighttime environment very dark, very quiet, and as comfortable as possible.
  • Avoid nicotine.
  • Avoid alcohol too close to bedtime. Although alcohol may make it easier to fall asleep, you are likely to wake up hours later when it leaves your bloodstream. If you are having difficulty sleeping, it may be best to cut out alcohol entirely.
  • Avoid caffeine after lunchtime. Some individuals with a high sensitivity to caffeine may need to cut it out entirely.
  • Keep a regular routine and get up at the same time every day.

. Stressed-out American Women Have No Time for Sleep. National Sleep Foundation Web site. Available at:{F6BF2668-A1B4-4FE8-8D1A-A5D39340D9CB}/Poll%20Release%20-%20FINAL.pdf. Accessed September 25, 2008.

. Ancoli-Israel S, Liu L, Marler MR, et al. Fatigue, sleep, and circadian rhythms prior to chemotherapy for breast cancer. Supportive Care in Cancer. 2006;14(3):201-9.
3. Lis CG, Gupta D, Grutsch JF. The relationship between insomnia and patient satisfaction with quality of life in cancer. Supportive Care in Cancer. 2008;16(3):261-66
4. Berger AM, Mitchell SA. Modifying cancer-related fatigue by optimizing sleep quality. Journal of the National Comprehensive Cancer Network. 2008;6(1):3-13.
5. DiStasio SA. Integrating yoga into cancer care. Clinical Journal of Oncology Nursing. 2008;12(1):125-30.
6. Clinical Research page, Litebook Web site. Available at: Accessed September 25, 2008.

7. Fiorentino L, Ancoli-Israel S. Sleep dysfunction in patients with cancer. Current Treatment Options in Neurology. 2007;9(5):337-46.

8. Epstein DR, Dirksen SR. Randomized trial of a cognitive-behavioral intervention for insomnia in breast cancer survivors. Oncology Nursing Forum. 2007;34(5):E51-59.
9. Dirksen SR, Epstein DR. Efficacy of an insomnia intervention on fatigue, mood and quality of life in breast cancer survivors. Journal of Advanced Nursing. 2008;61(6):664-75.
10. National Institutes of Health State-of-the-Science Conference Statement: Management of Menopause-related Symptoms. Annals of Internal Medicine Web site. Accessed September 25, 2008.
11. Find a Sleep Professional. National Sleep Foundation Web site. Available at: Accessed September 25, 2008.
12. Academy of Cognitive Therapy Web site. Available at: Accessed September 25, 2008.
13. Web site. Available at: Accessed September 25, 2008.
14. The Beck Institute for Cognitive Therapy and Research. Available at: Accessed September 25, 2008.

15. National Sleep Foundation/Better Sleep Council Sleep Tips. Better Sleep Council Web site. Available at: Accessed September 25, 2008.
16. “10 Tips for Better Sleep. Mayo Clinic Web site. Available at: Accessed September 25, 2008.

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