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Trouble sleeping is very common during and after cancer treatment, and it often lasts. Your team should ask about your sleep at every stage. The treatment with the best evidence is cognitive behavioural therapy for insomnia (CBT-I), face to face or online. Sleeping tablets can help for a short time but are not recommended for long-term use; exercise can help too.
ESMO (2023) recommends that every patient with cancer be screened and assessed for insomnia regularly, from diagnosis through treatment and survivorship [I, A]; that people who screen positive have their severity measured with a validated tool, with the Insomnia Severity Index recommended [II, B]; and that a clinical interview is needed for a detailed evaluation [I, A]. CBT-I is the standard of care for insomnia in cancer survivors [I, A]. Where face-to-face CBT-I cannot be had, electronic CBT-I should be offered [II, A]; brief behavioural therapy should be considered during active treatment [II, B]; and mindfulness-based therapy is an alternative when CBT-I is not available or is preferred [II, B]. Exercise tailored to the person should be offered alone or alongside [II, B].
Hypnotics are an option, but their limited evidence of benefit does not outweigh the harms of long-term use [II, C]; short-term use of up to two weeks is not ruled out. Melatonin should be considered when circadian disruption is thought to maintain the insomnia and non-drug options are limited [II, B]; ESMO notes studies used 2 to 20 mg and that there is no dosing recommendation. Bright light therapy has insufficient evidence [II, C]. MASCC (2023) found no high-quality evidence to recommend cannabis for insomnia or other psychological symptoms in cancer.
Why: Sleep problems are common, often start with the diagnosis and treatment, and can last for years if nobody asks.
“All patients with cancer should be regularly screened and assessed for insomnia during all phases of their treatment (e.g. after diagnosis and prior to surgery or any other primary treatment) and during the survivorship trajectory [I, A]”
ESMO, ESMO Open 2023 · [I, A]
Why: A score shows how severe the problem is and whether treatment is working.
“The ISI is recommended for assessment of insomnia severity in patients with cancer [II, B]”
ESMO, ESMO Open 2023 · [II, B]
Why: Insomnia is tangled up with pain, worry, depression and tiredness, and each makes the others worse; the interview finds what to treat.
“A clinical interview is needed for a detailed insomnia evaluation [I, A]”
ESMO, ESMO Open 2023 · [I, A]
Why: CBT-I, which retrains sleep habits and the worries that keep people awake, has the strongest evidence and lasting effects without the risks of tablets.
“CBT-I is recommended as the standard of care for treating insomnia in cancer survivors [I, A]”
ESMO, ESMO Open 2023 · [I, A]
Why: Online programmes worked about as well in trials, and a shorter version is easier to manage while having treatment.
“eCBT-I should be offered to cancer survivors with insomnia when face-to-face CBT-I is not available due to cost, lack of trained therapists, or physical or geographical constraints [II, A]”
ESMO, ESMO Open 2023 · [II, A]
Why: Exercise improves sleep and has wider benefits after cancer.
“While currently available evidence is moderate, the general benefits of physical exercise suggest that exercise tailored to the patient’s abilities and needs should be offered as a stand-alone or supplementary intervention for insomnia in patients with cancer and cancer survivors [II, B]”
ESMO, ESMO Open 2023 · [II, B]
Why: The evidence that they help is limited, and long-term use brings side effects and risks.
“Hypnotics are an option for treating insomnia in patients with cancer and cancer survivors; however, the limited evidence for efficacy does not outweigh the side-effects and risks of AEs associated with long-term use [II, C]. This recommendation does not preclude short-term use (≤2 weeks).”
ESMO, ESMO Open 2023 · [II, C]
Why: Melatonin may help when the body clock is out of step, and it has few side effects.
“Melatonin should be considered in patients with cancer and cancer survivors when circadian rhythm disruption is believed to be an important factor in maintaining the insomnia and when suitable nonpharmacological options are limited [II, B]”
ESMO, ESMO Open 2023 · [II, B]
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
ESMO 2023 is the latest specialist guideline found and was read in full: screen everyone regularly, assess with the Insomnia Severity Index and a clinical interview, and treat with CBT-I first [I, A], electronic CBT-I where face-to-face therapy is unavailable [II, A], brief behavioural therapy during active treatment [II, B], mindfulness-based therapy as an alternative [II, B] and exercise alongside [II, B]. Hypnotics are for short-term use only [II, C]. ESMO notes that the American College of Physicians, the European Sleep Research Society and the American Academy of Sleep Medicine also recommend CBT-I as standard care for insomnia in general. MASCC (2023) does not recommend cannabis for insomnia in cancer.
ESMO, ESMO Open 2023 · MASCC, Supportive Care in Cancer 2023
Where it differs: A shorter behavioural programme, with less burden on the patient, in place of full CBT-I while treatment is ongoing.
Evidence: Recommended by ESMO for patients in active treatment [II, B].
Where it differs: Mindfulness training instead of CBT-I.
Evidence: ESMO: to be offered when CBT-I is not available or the survivor prefers it [II, B]; in the meta-analysis ESMO cites it was better than attention-control conditions such as sleep hygiene education.
Where it differs: Advice on caffeine, alcohol, screens and the bedroom, without the other parts of CBT-I.
Evidence: ESMO describes sleep hygiene education as one component of CBT-I, and cites mindfulness-based therapy outperforming sleep hygiene education as an attention-control condition; it is not recommended as a stand-alone treatment in any source read.
Where it differs: Cannabis or cannabinoids used for insomnia.
Evidence: MASCC (2023): of 15 randomised trials, none assessed psychological symptoms as the primary outcome; no high-quality evidence to recommend it.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Bright light therapy for insomnia “There is currently insufficient evidence to support the use of bright light therapy in treating insomnia in patients with cancer and cancer survivors [II, C]” | [II, C] | ESMO, ESMO Open 2023 |
| Mindfulness-based therapy as an alternative to CBT-I “MBT should be offered to cancer survivors with insomnia when CBT-I is not available or when MBT is preferable to survivors [II, B]” | [II, B] | ESMO, ESMO Open 2023 |
| Brief behavioural therapy during active treatment “BBT-I, which reduces the patient burden of the intervention, should be considered for patients in active treatment for cancer who are experiencing insomnia [II, B]” | [II, B] | ESMO, ESMO Open 2023 |
| Cannabis for psychological symptoms including insomnia “There is no high-quality evidence to recommend the use of cannabis as an intervention for psychological symptoms in patients with cancer until more high-quality research demonstrates benefit.” | no high-quality evidence (MASCC) | MASCC, Supportive Care in Cancer 2023 |
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Shares European Society for Medical Oncology (ESMO) and the tags protocol, supportive-care.
Shares European Society for Medical Oncology (ESMO) and the tags protocol, supportive-care.