Healio Interviews

Disclosures: Ancoli-Israel, Davis, Mao and Zhou report no relevant financial disclosures.
February 23, 2022
4 min read

‘Unlearning’ bad habits, addressing comorbidities key to better sleep for cancer survivors


Healio Interviews

Disclosures: Ancoli-Israel, Davis, Mao and Zhou report no relevant financial disclosures.
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Because insomnia can occur among cancer survivors for a wide variety of reasons, there is not necessarily a “one-size-fits-all” approach to its treatment.

According to Mellar P. Davis, MD, FCCP, FAAHPM, director of palliative care at Geisinger Medical Center, a clinician should begin by ruling out potential sleep disorders or other comorbidities that may at the root of the insomnia.

“One of the things one should look for are sleep disorders that either were pre-existing or became evident during active treatment or in survivorship.” - Mellar P. Davis, MD, FCCP, FAAHPM

“One of the things one should look for are sleep disorders that either were pre-existing or became evident during active treatment or in survivorship,” Davis said in an interview with Healio. “A number of survivors are on opioids, which can bring out obstructive or central sleep apnea. Another condition is restless leg syndrome. These require specific treatments, and initially, you need to see if a patient has one of these sleep-related disorders because there are targeted treatments for them.”

Similarly, if a survivor is struggling with concomitant depression, the use of appropriate antidepressants may alleviate insomnia, Davis said.

“It may be that by treating the depression, we will see the insomnia improve,” he said. “Then, probably the best treatment with the most evidence is cognitive behavioral therapy.”

CBT-I: The mainstay of insomnia treatment

One of the most effective treatments for insomnia in cancer survivors is a specialized type of evidence-based psychotherapy called cognitive behavioral therapy for insomnia (CBT-I). This type of therapy differs from general CBT in that it is focused specifically on “unlearning” bad habits around sleep.

“This is a very specific tool set for treating the etiology of the insomnia,”,” Eric Zhou, PhD, faculty member in the division of sleep medicine and assistant professor of pediatrics at Harvard Medical School, said in an interview with Healio. “They’ve just learned to sleep the wrong way, and they have to ‘unlearn,’ those behaviors, habits and thoughts. This is considered frontline therapy for healthy adults.”

Zhou said despite its effectiveness, CBT-I tends to be underused among cancer survivors, partly because of the use of pharmacologic treatments for longer durations than necessary.

“I see patients who are started on lorazepam, for example, at the beginning of treatment or just after diagnosis, when they are in the throes of anxiety about their cancer,” he said. “That may be a suitable time to use pharmacotherapy for insomnia. The problem is, now these patients are 12 years into survivorship and they’re still taking the lorazepam.”

CBT-I usually consists of six to eight sessions addressing behavioral issues that can contribute to insomnia. However, this treatment may not be accessible to patients living in more remote areas, according to Jun J. Mao, MD, MSCE, chief of integrative medicine service at Memorial Sloan Kettering Cancer Center.

“CBT-I may not be available in all areas,” he said. “In those cases, nonpharmacologic interventions like acupuncture, yoga and meditation have also been shown to be effective in addressing insomnia in cancer survivors.”

Getting quality sleep

In CBT-I, survivors are taught to revise some of the intuitive behaviors that may seem useful in aiding sleep but may instead worsen the situation. According to Sonia Ancoli-Israel, PhD, professor emeritus of psychiatry at University of California San Diego School of Medicine, CBT-I involves educating the patient about sleep and then teaching them to modify unhelpful behaviors.

“The treatment consists of behavioral changes; one is called stimulus control therapy, which basically says that the bed is used only for sleep,” Ancoli-Israel said in an interview with Healio. “You don’t read in bed; you don’t have a phone or clock in bed. You are only in bed when you are ready for sleep.”

When sleep is elusive, Ancoli-Israel recommends that the patient leave the bedroom.

“I would tell patients that as soon as you start getting tense and anxious about the fact that you are not falling asleep, you get out of bed,” she said. “Whether it’s the beginning of the night or the middle of the night, you go into another room and do something that is quiet and relaxing until your eyes are ready to close. Then you go back to bed.”

Trying to compensate for lost sleep by getting more sleep the following night is also considered an ineffective approach. According to Zhou, more sleep does not necessarily equal quality sleep.

“People should be getting the right amount of sleep at a consistent time that is consolidated, meaning it’s as uninterrupted as possible,” he said. “This is in direct contrast to what people with insomnia often do, which is to try to get as much sleep on any given night as possible. We’re trying to undo that — instead of trying to get more sleep, we want patients to get the right amount of quality sleep. That’s what CBT-I does. It changes the approach to sleep by structuring it differently.”

The potential of light therapy

Ancoli-Israel has also done research on the use of light therapy to regulate circadian rhythms among patients with and survivors of breast cancer. In a study published in Journal of Clinical Sleep Medicine, Ancoli-Israel and colleagues evaluated the use of systemic light exposure on a group of 44 fatigued cancer survivors.

She said she conducted this research to understand the “feedback loop” of fatigue and insomnia that patients and survivors of cancer may experience. She noted that although the light therapy was not specifically intended to treat insomnia, it did yield some improvements in fatigue.

“It kept fatigue from getting worse, and overall, their circadian rhythms were better,” she said. “They also showed improved quality of life, and some improvement in sleep.”
-alone treatment for cancer survivors with insomnia, she would like to see further research done on this subject.

“The light therapy is not the best treatment for insomnia — CBT-I is the best treatment for that,” she said. “One study I would really like to see would be on the combined effect of light and cognitive therapy. That way you are targeting everything.”


For more information:

Sonia Ancoli-Israel, PhD, can be reached at

Mellar P. Davis, MD, FCCP, FAAHPM, can be reached at

Jun J. Mao, MD, MSCE, can be reached at

Eric Zhou, PhD, can be reached at