Poor Quality Sleep: A Silent Source of Disability in Breast Cancer

There are many causes for sleep disturbances in breast cancer sufferers, including age, socioeconomic status, lifestyle choices, and other co-existing medical conditions. Some of the prominent contributors to poor sleep, however, are the treatments themselves.
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By: Hrayr Attarian, MD, FACCP, FAASM, Member of the SWHR Network on Sleep and Associate Professor of Neurology, Northwestern University, Circadian Rhythms and Sleep Research Lab for the Society for Women's Health Interdisciplinary Network on Sleep

Poor quality sleep is a major contributor to reduced quality of life and can have a negative impact on mood and energy, cognition, metabolic and immunological function, as well as lead to weight gain [3].

Sleep-related complaints are quite common in women with breast cancer, affecting around 70 percent of them [1]. In fact, more than 60 percent of women with either metastatic and non-metastatic disease are diagnosed with insomnia [1,2]. This prevalence exceeds both age-matched healthy adults and women afflicted by other cancers [3].

There are many causes for sleep disturbances in breast cancer sufferers, including age, socioeconomic status, lifestyle choices, and other co-existing medical conditions. Some of the prominent contributors to poor sleep, however, are the treatments themselves. Chemotherapy and radiation therapy are associated with more sleep disturbances than hormonal treatments and surgery. In fact, surgery reduced the occurrence of insomnia from 69 percent to 42 percent in a group of women with non-metastatic breast cancer [2].

Causes for chemotherapy-related sleep disturbances include distressing side effects such as nausea, vomiting, diarrhea, and frequent urination. A longitudinal study over a period of one year showed that both subjective and objective measures of sleep got worse with each cycle of chemotherapy in 80 percent of women with breast cancer. Radiation from chemotherapy can cause painful reactions to the area of the skin where it is applied and this pain can interfere with sleep.

In addition to the pain, frequent hospital stays, stress, depression, fatigue, and even negative body image issues due to surgery all can lead to significant deterioration in sleep quality. Additionally, menopause-like "vasomotor" symptoms of hot flashes and night sweats can disturb sleep, and are common with either chemotherapy-induced ovarian failure or as a result of hormonal treatments.

But cancer therapy and its side effects are not the only contributors to sleep disturbances. The size of the tumor and its aggressiveness or degree of spread also adversely impact sleep. The quality of a woman's sleep prior to her diagnosis with breast cancer is also an important contributor to the likelihood and severity of insomnia after diagnosis [3].

Despite the prevalence of disturbed sleep and related fatigue in breast cancer survivors, there are relatively few studies looking into remedies for it. The most promising treatments are not pharmacological; instead, these treatments are behavioral interventions and complementary and alternative therapies. Structured Yoga [5], exercise programs [6] and bright light exposure [7] all have been shown to improve sleep and overall well-being in breast cancer survivors.

In severe cases of insomnia, a short-term, structured cognitive behavioral therapy program also has been shown to be effective in significantly improving sleep and quality of life in breast cancer patients [8]. Sleep medications should only be used for very brief periods and only for acute cases of insomnia, as there isn't enough data available on the long-term effects of use [9].

With better treatments and reduced mortality, breast cancer itself accounts for the majority of disability-adjusted life years (DALY) lost to all cancers [3]. It is imperative, therefore, to increase awareness of sleep disorders in women with breast cancer and to come up with effective and safe treatments to improve both sleep and quality of life in this population.

SWHR is dedicated to bringing together experts to study sex and gender differences in sleep and the state of women's sleep health. Click here to learn more about SWHR's Interdisciplinary Network on Sleep.


1) Palesh OG, Collie K, Batiuchok D, et al. A longitudinal study of depression, pain, and stress as predictors of sleep disturbance among women with metastatic breast cancer. Biol Psychol 2007;75:37-44.

2) Savard J, Ivers H, Villa J, et al. Natural course of insomnia comorbid with cancer: an 18-month longitudinal study. J Clin Oncol 2011;29:3580-3586.

3) Costa AR, Fontes F, Pereira S, Gonçalves M, Azevedo A, Lunet N. Impact of breast cancer treatments on sleep disturbances - A systematic review. Breast. 2014;23(6):697-709.

4) Ancoli-Israel S, Liu L, Rissling M, et al. Sleep, fatigue, depression, and circadian activity rhythms in women with breast cancer before and after treatment: a 1-year longitudinal study. Support Care Cancer 2014;22:2535-2545.

5) Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for sleep quality among cancern survivors. J Clin Oncol 2013;10;31:3233-3241.

6) Young-McCaughan S, Mays MZ, Arzola SM, et al. Research and commentary: change in exercise tolerance, activity and sleep patterns, and quality of life in patients with cancer participating in a structured exercise program. Oncol Nurs Forum 2003;30:441-454.

7) Neikrug AB, Rissling M, Trofimenko V, et al. Bright light therapy protects women from circadian rhythm desynchronization during chemotherapy for breast cancer. Behav Sleep Med 2012;10:202-216.

8) Savard J, Simard S, Ivers H, Morin CM. Randomized study on the efficacy of cognitive-behavioral therapy for insomnia secondary to breast cancer, part I: sleep and psychological effects. J Clin Oncol 2005;23:6083-6096.

9) Jacobsen PB, Massie MJ, Kinne DW, Holland JC. Hypnotic efficacy and safety of triazolam administered during the postoperative period. Gen Hosp Psychiatry 1994;16:419-425.


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