Why Cognitive Behavioral Therapy for Insomnia Remains the Gold Standard in Oncology

Sleep disturbances is a pervasive challenge for patients undergoing cancer treatment, often triggered by the physiological tolls of chemotherapy, hospitalizations, and the psychological weight of diagnostic anxiety. While many patients naturally return to a typical sleep cycle after these disruptions, for others, insomnia persists through a cycle of maladaptive behavioral changes and classical conditioning.

In this interview with CancerNetwork, live from the 2026 American Psychosocial Oncology Society (APOS) Annual Conference in New Orleans, Ben Brewer, PsyD, broke down the mechanics of cognitive behavioral therapy for insomnia (CBT-I). Brewer explained why this multifaceted approach is the primary recommendation for both the general population and patients with cancer, moving beyond simple sleep hygiene to address the powerful behavioral and cognitive factors that sustain chronic wakefulness.

Brewer is associate professor in medicine-hematology at the University of Colorado Anschutz.

Transcript:

[Cognitive behavioral therapy] is the first line recommended treatment for [patients with] cancer, and if you have insomnia in the general population. It’s the first line recommended treatment. It is composed of 5 major components. There are 5 behavioral components of cognitive behavioral therapy. The first one is, we call it stimulus control, and that is essentially just sleeping in bed and not sleeping anywhere else, and taking any awake time out of bed, doing that somewhere else. What that does is it just gives you a chance to reestablish the bed as a place of sleep.

One of the problems that we have, and that [patients with] cancer specifically have is that they get their sleep disrupted by chemotherapy, a hospital admission, anxiety, whatever it is, and then normally, people go back to sleep after that disruption.

However, in [patients] with insomnia, it persists due to behavioral changes. [Patients] might do unusual things like trying to go to go to bed early to get a lot of sleep, which doesn’t help if it’s not your natural time to go to sleep. Then it also persists because of these condition factors that are in large part, there’s many other factors, but some of them are Pavlovian. It’s classical conditioning. With the stimulus control I was mentioning, we do a little bit of sleep restriction, or sleep compression, which is where you have them just sleep—just spend the time in bed that’s a little over their sleep time. That’s sleep compression. That works well, but those 2 components help to reset that conditioning. For a period of time, you strictly do that. You clear out that Pavlovian conditioning, and then you’ve reconditioned the bed as a place of sleep. That’s a main component of how this works, particularly in the cancer population. I find that to be very effective.

There are other components. Relaxation training is one of them, which, for obvious reasons, is helpful at bedtime or if you have early morning awakening. There is also cognitive therapy, like addressing fear and unhelpful beliefs around sleep, unhelpful thoughts that pop up when you think of sleep. I thought, ‘Wow, I’m going to have a terrible night’s sleep tonight, because I have a scan coming up in a week’. That could be true, but thinking about it also can make it true. We can adjust the thinking in patients using cognitive therapy, which works well.

Then we have sleep hygiene, which is optimizing the room and the environment and the person for sleep. This includes having a wind down period, having things be at the right temperature, etc. A lot of people know that, and they think that that is cognitive behavioral therapy. The most effective components are these behavioral components that I started with. The other ones are useful. Relaxation is very useful. Sleep hygiene is effective, but if you have insomnia, you probably need to start with the other components too.