Experts are addressing the diagnosis and treatment of insomnia in cancer patients, emphasizing approaches such as sleep hygiene, cognitive behavioral therapy for insomnia (CBT-I), and medication. Insomnia is frequently encountered by oncologists but is often managed reactively with medication instead of through a comprehensive evaluation.
Read More
In a recent episode of Oncology On the Go, Daniel C. McFarland, DO, conversed with psychiatrist and psycho-oncologist Virginia C. O’Brien, MD, to explore more effective evaluation and treatment methods for insomnia in cancer patients. They began by differentiating between primary and secondary insomnia, highlighting that secondary insomnia—often caused by anxiety, depression, pain, or cancer treatments—is prevalent in oncology populations.
O’Brien noted that a common error is to prescribe medication without conducting a thorough sleep history. This history should include details about which sleep phases are disrupted and the overall impact on daytime functioning. The discussion then transitioned to practical sleep hygiene tips for patients, including limiting caffeine and screen time, managing bedroom environments, and establishing a consistent sleep routine.
The conversation moved to CBT-I, which is recommended as the first-line treatment for insomnia. O’Brien explained that while sleep restriction can be beneficial, it may be challenging during active chemotherapy. She also recommended free digital resources such as CBT-i Coach to improve access to treatment.
The latter part of the exchange focused on pharmacological options for managing insomnia, discussing the appropriate times to use medications. They covered how to select from various options, ranking them by their potential for dependence. Specific medications referenced include trazodone (Desyrel), ramelteon (Rozerem), zolpidem (Ambien, including FDA dosing cautions for women), benzodiazepines, and newer orexin receptor antagonists. The experts laid special emphasis on considerations for older patients at risk of falls and those with a history of substance use disorder.
They concluded with recommendations for when to refer patients to sleep specialists, including the use of the STOP-BANG screening tool for obstructive sleep apnea and signs indicating potential parasomnias such as REM sleep behavior disorder.
McFarland serves as the director of the Psycho-Oncology Program at Wilmot Cancer Center and specializes in head, neck, and lung cancers, while O’Brien is the system director of Ambulatory Psychiatry at the Carilion Clinic.
For further insights on managing insomnia in cancer patients, McFarland and O’Brien recommend referring to the European Society of Medical Oncology Clinical Practice Guidelines.