Managing Insomnia in Cancer Care: Sleep Hygiene, CBT-I, and Medications

Insomnia is one of the most common symptoms oncologists are asked to manage, yet it’s often treated reactively with medication rather than through a structured, history-driven approach. In this episode of Oncology On the Go, Daniel C. McFarland, DO, sat down with psychiatrist and psycho-oncologist Virginia C. O’Brien, MD, to unpack how clinicians can more effectively evaluate and treat insomnia in patients with cancer.

The conversation opened with a foundational distinction: primary vs secondary insomnia, and why secondary insomnia—driven by anxiety, depression, pain, or cancer treatment itself—is far more common in oncology populations. O’Brien emphasized that the most frequent clinical mistake is jumping straight to a prescription instead of taking a thorough sleep history, including which phase of sleep is disrupted (falling asleep, staying asleep, or early waking) and whether the problem is affecting daytime functioning.

From there, the discussion moved through practical sleep hygiene strategies clinicians can share with patients, such as limiting caffeine and screens, managing pets and partners in the bedroom, and setting a consistent nighttime routine. Then, they dove into cognitive behavioral therapy for insomnia (CBT-I), the first-line recommended treatment. O’Brien explained how sleep restriction works, why it’s often impractical during active chemotherapy, and how free digital tools like CBT-i Coach can help fill access gaps.

The latter part of the discussion tackled pharmacologic management in detail: when medications are appropriate for acute insomnia; how to sequence options from least to most habit-forming; and specific guidance on trazodone (Desyrel), ramelteon (Rozerem), zolpidem (Ambien; including FDA dosing warnings for women), benzodiazepines, and newer orexin receptor antagonists. Special attention was given to older patients, those with a fall risk, and patients with a history of substance use disorder.

The experts closed with guidance on when to refer to a sleep medicine specialist, including STOP-BANG screening for obstructive sleep apnea and red flags for parasomnias like REM sleep behavior disorder.

McFarland is the director of the Psycho-Oncology Program at Wilmot Cancer Center and a medical oncologist who specializes in head, neck, and lung cancer, in addition to being a psycho-oncology editorial advisory board member for the journal ONCOLOGY®. O’Brien is system director of Ambulatory Psychiatry at the Carilion Clinic.