Evidence-based ways to address sleep problems during and after cancer treatment, from CBT-I to mind-body practices to simple daily rhythms.
In Part 1 of this series, we looked at how and why sleep so often unravels during and after cancer treatment: side effects and medications, hormone changes, worry, stress, a disrupted body clock, and a cluster of symptoms that feed one another. If you haven't read it yet, it's a good place to start. But otherwise, let’s take a look at what can you actually do about it.
The short answer is that there is actually a lot that you can do, and much of it has remarkably strong research behind it. Below are seven places to start. One caveat before we begin (and it's an important one): nothing here can replace the guidance of your oncology or healthcare team. If you have one, think of this as a map of options to explore with them.
What Can Help
1. Name It
It sounds obvious, but it's the step that most often gets skipped. A 2020 review noted that insomnia is rarely addressed systematically in oncology clinics (Kwak et al., 2020), which means you may need to be the one to raise it. When you do, a sleep assessment typically includes a physical exam, a health history, and a sleep history, and treating sleep problems may involve supportive care for the side effects of cancer or its treatment (PDQ Supportive and Palliative Care Editorial Board, n.d.-b). The National Cancer Institute (NCI) also notes that sleep should be reassessed from time to time, because how severe it is can change.
This matters because sleep trouble has so many possible drivers. Treating pain, hot flashes, or nausea may do more for your nights than any sleep-specific tool. And other sleep disorders, such as sleep apnea, or restless leg can also occur (PDQ Supportive and Palliative Care Editorial Board, n.d.-a). A simple tip: keep a basic sleep diary (when you went to bed, roughly when you fell asleep, when you woke, how you felt) for a week or two. It gives your team or other professional (and even yourself!) something concrete to work with.
2. Try CBT-I (Cognitive Behavioral Therapy for Insomnia)
Admittedly, I’m a bit biased (I hold a certificate in CBT-I and draw on it with nearly all my sleep clients). But CBT-I is the gold-standard, treatment for sleep problems and it’s solidly backed up with a lot of research. Also, I have experienced its benefits first hand through my own experience as well as that of my clients. CBT-I just works. (So, there’s good reason for my bias.)
A 2024 systematic review and meta-analysis in JNCI Cancer Spectrum analyzed 61 randomized controlled trials involving over 6,500 people with cancer. CBT-I emerged as the most effective intervention for reducing insomnia severity in cancer survivors, to great effect right after treatment. It also produced significant improvements in fatigue, depressive symptoms, and anxiety (Nissen et al., 2024). That is a lot to ask of a non-drug treatment, and it's why CBT-I is also the recommended first-line treatment for chronic insomnia in general (Qaseem et al., 2016; Edinger et al., 2021).
What does it involve? In one trial of people with cancer, the CBT-I program included stimulus control (strengthening the link between your bed and sleep), sleep restriction (carefully adjusting your time in bed so that sleep becomes deeper and more consolidated), cognitive therapy (examining the thoughts that fuel sleep anxiety), and relaxation training (Garland et al., 2014).
Two things are worth knowing. First, CBT-I is adaptable. The same review found that Brief Behavioral Therapy for Insomnia showed promise as a less burdensome alternative for people in active treatment (Nissen et al., 2024). Adaptation is important because sleep problems are as unique as the person experiencing them. The best treatment for you is always one that meets you where you are in order to take you where you want to be. CBT-I strategies are inherently built to your unique situation. And, it doesn't always have to be in person. The National Cancer Institute notes that video CBT sessions have been shown to be helpful when in-person sessions aren't available (PDQ Supportive and Palliative Care Editorial Board, n.d.-b), which is a real relief when energy and travel are limited.
3. Consider Mindfulness-Based Approaches
In a randomized trial of over 100 people with cancer who had completed primary treatment, researchers compared mindfulness-based stress reduction (MBSR) directly with CBT-I. CBT-I produced faster and more durable (longer lasting) improvement in insomnia, and the researchers concluded that it remains the best choice for treating insomnia without medication. But, MBSR was a close second. It matched CBT-I at follow-up, and both approaches reduced stress and mood disturbance (Garland et al., 2014).
So if CBT-I isn't available or doesn't appeal to you, mindfulness is an evidence-supported alternative. (Admittedly, the larger review I mentioned above found that mindfulness-based therapies showed benefit, but with less convincing evidence than CBT-I [Nissen et al., 2024].) In my own work, I often see the two complement each other well. And, I draw upon both depending upon specific client needs. Which is to say, that drawing on both is certainly fair game for you too.
4. Move Gently (and Consider Yoga)
In a large multicenter trial, 410 cancer survivors with moderate or greater sleep disruption (all between 2 and 24 months after surgery, chemotherapy, and/or radiation) were assigned to standard care or standard care plus a four-week yoga program that combined breathing exercises, gentle postures, and meditation. The yoga group showed greater improvements in overall sleep quality, time awake after falling asleep declined, sleep efficiency increased, and reliance on sleep medication dropped (Mustian et al., 2013). Most participants in that trial were women (96%), and about three-quarters had breast cancer, so it's worth keeping in mind that results may differ for others.
The broader review found that exercise and mind-body therapies showed benefits, again with evidence that was less convincing than for CBT-I (Nissen et al., 2024). Still, there's a lot to like about gentle movement: it supports mood, energy, and a sense of agency in a body that has been through a lot. I wrote about how movement, mood, and sleep feed one another in my article on the positive feedback loop. As always, check with your oncology team about what kind and amount of activity is right for you.
5. Anchor Your Days and Protect Your Nights
Remember the disrupted body clock from Part 1? The good news is that you can help re-anchor it. Things like light therapy has shown benefits for sleep in people with cancer, though again with evidence less convincing than CBT-I [Nissen et al., 2024]. The practical takeaways below are my own approach, in line with how we think about circadian rhythms. Here's what I typically suggest:
Keep a consistent wake-up time, as best you can, even after a rough night.
Get some daylight early in the day. Even sitting by a bright window helps signal "day" to your body.
Be thoughtful about naps. Rest is not the enemy, and during treatment you may truly need it. But long or late naps make sleep at night significantly tougher, so if you can, keep them short and earlier in the day.
Keep your bed for sleep. The more your brain connects the bed with rest (and not with scrolling or worrying), the better.
Don't chase a number. I wrote about why eight hours is more myth than rule, and that's especially true when your body is recovering.
6. Be Careful With Sleep Aids and Supplements
It's completely understandable to want something that works tonight. Research does show that sleep medication and melatonin can offer benefit for people with cancer, but the evidence for them was less convincing than for CBT-I (Nissen et al., 2024). And because medications and supplements can interact with cancer treatment, this is one place where I'd strongly encourage you to involve your oncology team before taking anything new. Interestingly, the yoga trial above found that participants used less sleep medication afterward (Mustian et al., 2013), which suggests that building skills (through embodied practices and sleep-friendly choices) can reduce reliance on pills.
7. Don't Skip the Emotional Side
Because fear of recurrence is a well-documented contributor to insomnia (Kwak et al., 2020), and anxiety and depression are highly correlated with sleep disturbance (PDQ Supportive and Palliative Care Editorial Board, n.d.-a), caring for your emotional well-being is part of caring for your sleep. For many people, that means talking with a counselor, a support group, or a spiritual care provider. These are the places where fears can be voiced and processed rather than carried alone into the night.
And please tell your care team if you notice persistent sadness or hopelessness. If low mood ever turns into thoughts of harming yourself, please call or text 988 right away.
A Closing Thought
Adam Scheldt is a CBT-I sleep coach, and educator based in Kenmore, New York, serving clients in person and online.
If there's one thing I'd like you to take from this series, it's that sleep trouble with cancer is common, understandable, and treatable. Not every approach works for everyone, and it may take some experimenting to find the combination that fits you. But, you have more options than you might think. Some are in the hands of your oncology team, some in the habits and thoughts that shape your nights, and some in the kind of structured support that CBT-I offers.
If you'd like a partner in figuring out what a better night could look like, I am here. I work with clients in person across Western New York and online, which can make support far more accessible when energy is limited. You don't have to endure sleepless, exhausted nights on top of everything else. Restful sleep is within reach. And as always, I am here to help you explore what that can look like and help you get the rest you deserve.
Be well.
References
Edinger, J. D., Arnedt, J. T., Bertisch, S. M., Carney, C. E., Harrington, J. J., Lichstein, K. L., Sateia, M. J., Troxel, W. M., Zhou, E. S., Kazmi, U., Heald, J. L., & Martin, J. L. (2021). Behavioral and psychological treatments for chronic insomnia disorder in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 17(2), 255-262. <https://doi.org/10.5664/jcsm.8986>
Garland, S. N., Carlson, L. E., Stephens, A. J., Antle, M. C., Samuels, C., & Campbell, T. S. (2014). Mindfulness-based stress reduction compared with cognitive behavioral therapy for the treatment of insomnia comorbid with cancer: A randomized, partially blinded, noninferiority trial. Journal of Clinical Oncology, 32(5), 449-457. <https://doi.org/10.1200/JCO.2012.47.7265>
Kwak, A., Jacobs, J., Haggett, D., Jimenez, R., & Peppercorn, J. (2020). Evaluation and management of insomnia in women with breast cancer. Breast Cancer Research and Treatment, 181(2). <https://doi.org/10.1007/s10549-020-05635-0>
Mustian, K. M., Sprod, L. K., Janelsins, M., Peppone, L. J., Palesh, O. G., Chandwani, K., Reddy, P. S., Melnik, M. K., Heckler, C., & Morrow, G. R. (2013). Multicenter, randomized controlled trial of yoga for sleep quality among cancer survivors. Journal of Clinical Oncology, 31(26), 3233-3241.
Nissen, E. R., Neumann, H., Knutzen, S. M., Henriksen, E. N., Amidi, A., Johansen, C., Von Heymann, A., Christiansen, P., & Zachariae, R. (2024). Interventions for insomnia in cancer patients and survivors: A comprehensive systematic review and meta-analysis. JNCI Cancer Spectrum, 8(3), Article pkae041. <https://doi.org/10.1093/jncics/pkae041>
PDQ Supportive and Palliative Care Editorial Board. (n.d.-a). Sleep disorders (PDQ®): Health professional version. National Cancer Institute. <https://www.cancer.gov/about-cancer/treatment/side-effects/sleep-disorders-hp-pdq>
PDQ Supportive and Palliative Care Editorial Board. (n.d.-b). Sleep disorders (PDQ®): Supportive care, patient information. National Cancer Institute. <https://www.columbiadoctors.org/health-library/nci-pdq-cancer/sleep-disorders-pdq-supportive-care-patient-information-nci/>
Qaseem, A., Kansagara, D., Forciea, M. A., Cooke, M., & Denberg, T. D. (2016). Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 165(2), 125-133. <https://doi.org/10.7326/M15-2175>