Sleep Disruption

How do integrative experts manage sleep disruption?

Clinical practice guidelines

2013 clinical practice guidelines from the American College of Chest Physicians weakly recommend mind-body modalities and/or yoga as part of multidisciplinary approach for managing sleep difficulties among people with lung cancer.

Mixed evidence for overall sleep quality, indicating either a positive effect of walking or no effect of exercise.

Strong evidence that moderate to vigorous intensity aerobic training is associated with better overall sleep quality in the general population.

Moderate-intensity aerobic training, particularly walking, three to four times per week, for 30 to 40 min per session over 12 weeks is recommended.

Grade C: can be considered for the management of sleep disturbance in women with a history of breast cancer. Evidence provides some support for recommendation(s) but care should be taken in its application.

Grade D: can be considered, noting there is inconsistent evidence regarding its effectiveness

Yoga

Not recommended for the management of sleep disturbance in women with a history of breast cancer due to evidence that it is not effective:

Isoflavones

Vitamin E

The 2019 guideline recommends several traditional Chinese herbal blends or acupuncture for insomnia, depending on the specific pattern of symptoms.

NCCN guidelines for patients for survivorship care for cancer-related late and long-term effects lists these complementary therapies and self-care practices as strategies to manage sleep difficulties.

Evidence-based clinical practice guidelines for integrative oncology: complementary therapies and botanicals ›

The 2009 guidelines for complementary therapies and botanicals states that exercise and mind-body approaches—as part of a multidisciplinary approach—improve sleep, specifically mentioning these therapies and practices

Clinical practice guidelines on the evidence-based use of integrative therapies during and after breast cancer treatment › This set of guidelines has been endorsed by the American Society of Clinical Oncology (ASCO).¹Lyman GH, Greenlee H et al. Integrative therapies during and after breast cancer treatment: ASCO endorsement of the SIO clinical practice guideline. Journal of Clinical Oncology. 2018 Sep 1;36(25):2647-2655.

The 2017 Society for Integrative Oncology clinical practice guidelines regarding breast cancer patients provide these statements regarding these therapies and practices for sleep disturbances:

Gentle yoga can be considered for improving sleep

Insufficient evidence to recommend calendula cream, meditation, qigong, or acupuncture

Published programs and protocols

These protocolsa package of therapies combining and preferably integrating various therapies and practices into a cohesive design for care, programs, and approaches by leaders in integrative cancer care provide guidance for managing sleep disruption.

We do not recommend specific integrative protocols or programs but provide information for you to evaluate with your healthcare team.

Lise Alschuler, ND, FABNO, and Karolyn Gazella

Approaches are described for certain cancer types, or along with certain conventional therapy treatments, or for particular conditions including sleep disruption.

Keith Block, MD

Integrative physician and CancerChoices advisor Keith Block, MD, and his colleagues offer guidance about how and when to be active to promote normal sleep-rest (circadian) function.²Block KI, Block PB et al. Making circadian cancer therapy practical. Integrative Cancer Therapies. 2009 Dec;8(4):371-86.

In addition to the sleep hygiene practices › recommendations:

• Avoid exercising to exhaustion, which increases cortisol levels.
• Avoid evening exercise.
• Avoid overwork and other very stressful activities that could disturb sleep through anxiety and catecholamine release; see Managing Stress ›
• Do not lie in bed after waking up at night; if you don’t fall asleep again soon, get up and leve your bedroom.

Further mind–body guidelines:

• Develop a quality social-support network.
• When possible, delegate stressful tasks.
• Use cognitive-behavioral therapy for stress and insomnia issues.
• Adopt effective stress management techniques such as abdominal breathing.
• Fretting over lost sleep only increases anxiety; find practices that can help you let go of worries and intrusive thoughts.
• Keep a notebook for middle-of-the-night worries or thoughts.

Special guidance for people with cancer

Dr. Keith Block and his colleagues offer guidance to promote normal circadian (sleep-rest) function among people in chemotherapy treatment, with advanced disease, or experiencing wasting (cachexia).³Block KI, Block PB et al. Making circadian cancer therapy practical. Integrative Cancer Therapies. 2009 Dec;8(4):371-86.

Foods and eating patterns to emphasize:

• Eat foods high in both calories and nutrition: healthful concentrated carbohydrate sources such as vegetables, lower dietary fiber, and increased proteins, including fish, egg whites, l-glutamine, chlorella supplements, and whey protein.
• Eat more foods and oils rich in omega-3 fatty acids, such as flaxseed oil, soybean oil, and canola oil, medium-chain triglycerides in coconut oil or palm kernel oil, and to a lesser extent, omega-6s.
• Adjust your meal schedule to a grazing pattern of 6–8 meals daily.
• Shift your largest meal of the day to breakfast, when your appetite may be best.
• Supplement meals with whey protein, soy protein, and medium-chain triglyceride shakes
• For wasting (cachexia), use anti-inflammatory supplements such as curcumin, fish oil, boswellia, or scutellaria.

Foods and eating patterns to avoid or minimize:

• Reduce your dietary glycemic load, especially in the morning.
• Lower your salt intake to optimize your potassium–sodium intake and ratio
• Eliminate chemicals that overstimulate neuron receptors (excitotoxins) including monosodium glutamate (MSG) and aspartame.
• Avoid foods containing tyramine after dinner, which increase norepinephrine release.
• Avoid overly spiced foods or other foods that cause digestive problems during sleep.

Guidelines for exercise

• Reduce your emphasis on long sessions of aerobic exercise.
• Emphasize interval training—repeated short sessions of aerobic-type exercise.
• Emphasize strength or resistance training; use light weights or isometrics in short sessions repeated several times daily.
• Emphasize practices such as yoga, Pilates, qigong, or tai chi that increase flexibility.
• Do not overexercise, as this produces inflammation and increases cortisol.

Find and address imbalances in your body terrain

Further actions for balancing sleep, rest and activity and promoting restful sleep:⁴Alschuler LN, Gazella KA. The Definitive Guide to Cancer, 3rd Edition: An Integrative Approach to Prevention, Treatment, and Healing. Berkeley, California: Celestial Arts. 2010; Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Care. New York: Bantam Dell. 2009

Work in partnership with your doctor to assess and monitor hormone imbalances; this may involve lab tests.

Consider supplements as indicated:

• Take adaptogens—such as Siberian ginseng (eleuthero), rhodiola, ginkgo or American ginseng—purported to aid in normalization of stress reactions and improve energy; take only in the morning if your sleep is disturbed.
• Avoid stimulant supplements including B vitamins, tyrosine, phenylalanine, glutamine, ginsengs, dehydroepiandrosteron (DHEA) and licorice in the evening.
• Consume herbal sedative teas or supplements—lemon balm, chamomile, valerian, hops, l-theanine, mimosa bark (Cortex albizziae), lavender, passionflower.
• Take melatonin or 5-HTP at bedtime.

Lorenzo Cohen, PhD, and Alison Jefferies, MEd

Traditional medicine

Expert commentary

Melatonin and sleep

From CancerChoices staff: Melatonin is produced naturally by the pineal gland during the early hours of night, signaling and initiating the transition from wakefulness to sleep. Then during the day, melatonin production diminishes as your production of other hormones—serotonin and cortisol—increases. Individuals who experience sleep difficulties may have disrupted melatonin production. 

Bright light influences melatonin production. Bright light in the morning diminishes melatonin production while boosting serotonin and cortisol, leading to greater wakefulness and setting the stage for the next evening’s production of melatonin. But bright light exposure late in the evening—and especially blue-spectrum light such as from most television, computer, mobile phone, and other electronic screens—can disrupt melatonin production and delay the initiation of sleep.⁵Kostoglou-Athanassiou I, Treacher DF, Wheeler MJ, Forsling ML. Bright light exposure and pituitary hormone secretion. Clinical Endocrinology (Oxford). 1998 Jan;48(1):73-9. 

To optimize our natural melatonin cycles and benefits, evidence shows that we should curb bright light in the evening and increase bright light exposure in the morning.⁶Leproult R, Colecchia EF, L’Hermite-Balériaux M, Van Cauter E. Transition from dim to bright light in the morning induces an immediate elevation of cortisol levels. Journal of Clinical Endocrinology and Metabolism. 2001 Jan;86(1):151-7; Nesbitt AD. Delayed sleep-wake phase disorder. Journal of Thoracic Disease. 2018 Jan;10(Suppl 1):S103-S111. Treatments for sleep disruptions, such as delayed sleep-wake phase disorder, may reduce exposure to bright and blue-spectrum light in the evening. 

Cancer acts more aggressively in people with low nighttime production of melatonin, and people with cancer with high nighttime melatonin levels tend to have better outcomes.⁷Block KI. Life over Cancer: The Block Center Program for Integrative Cancer Treatment. New York: Bantam Dell. 2009. pp. 412-414; Lissoni P, Tancini G et al. Melatonin increase as predictor for tumor objective response to chemotherapy in advanced cancer patients. Tumori. 1988 Jun 30;74(3):339-45; Bubenik GA, Blask DE et al. Prospects of the clinical utilization of melatonin. Biological Signals & Receptors. 1998;7(4):195-219. Preliminary research also shows that bright light therapy in the morning can improve sleep in people with cancer.⁸Wu LM, Amidi A et al. The effect of systematic light exposure on sleep in a mixed group of fatigued cancer survivors. Journal of Clinical Sleep Medicine. 2018 Jan 15;14(1):31-39.

Melatonin can also be taken as a supplement to promote sleep. Learn more in this therapy review.

Therapies

Melatonin

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