Overview

Head and neck cancer (HNC) is a diverse group of malignancies that arise in the oral cavity, pharynx, larynx, and nasal cavity. These are associated with risk factors such as tobacco use, alcohol consumption, and human papillomavirus (HPV) infection. Common treatments for HNC entail surgery, chemotherapy and radiation therapy, and these treatments can negatively affect a patient’s quality of life. Sleep disturbances are common in patients with HNC, before and after treatment. This article explores the connections between HNC and sleep and describes how rHNC and its treatments can cause various sleep-related problems, which subsequently can have a severe impact on mental health in patients with HNC.¹

Risk factors

• Smoking: Tobacco contains carcinogens that can cause cancer. Any form of tobacco use can increase the risk of HNC, including using smoked tobacco (cigarettes, cigars, electronic cigarettes) and smokeless tobacco (chewing tobacco, betel quid). The survival rate of patients who continue to smoke is reduced, and their chance of cancer recurrence is higher²
• Alcohol: When drinking alcoholic beverages, humans can produce acetaldehyde, a carcinogenic metabolite of alcohol²
• HPV: Human papillomavirus is a sexually transmitted virus, primarily responsible for causing cervical cancer, but it’s also linked to certain head and neck cancers. HPV plays a pathologic role in a subset of head and neck cancers, particularly those in the oropharynx, and is responsible for the rising incidence of oropharyngeal cancer²

Treatment

• Surgery: Aim to remove the tumour with a margin of surrounding healthy tissue. Surgeons may also remove the lymph nodes in the neck if the cancer has spread or has a reasonably high risk of spreading there³
• Radiation therapy: The most common method for treating HNC uses a machine that directs high-energy X-rays at the cancer cells. Radiation therapy is received by patients alongside other treatments like surgery and chemotherapy
• Chemotherapy: Advised in advanced stages of HNC treatment. Drugs are used in chemotherapy to kill cancer cells. Most patients may receive chemotherapy alongside radiation therapy
• Immunotherapy: Drugs are administered to enhance the immune system’s ability to identify and destroy cancer cells. Pembrolizumab and nivolumab are immunotherapeutic drugs that can treat certain HNCs that have spread or returned post-treatment^1,4 

Sleep disturbances in cancer patients

Cancer patients usually complain about sleep disturbances even before undergoing treatment, a problem that can persist long after. It may be a key contributor to poor quality of life and can lead to mood disorders, particularly depression.⁵

Specific sleep challenges in HNC patients

• Physical effects of treatment: Physiological changes that directly impact the ability to achieve restful sleep
• Surgical treatments: Procedures can cause pain, difficulty breathing, dysphagia (difficulty swallowing). These surgeries may require the patients to use medical devices such as feeding tubes (tracheostomies), which can disrupt regular sleeping patterns and posture^4,6
• Radiation therapy: Tissue damage and other side effects, such as mucositis, mucormycosis, xerostomia (dry mouth), and skin irritation, can cause discomfort enough that it causes the patient to awaken frequently during the night.
• Chemotherapy: It can cause fatigue, nausea, neuropathy, and myelosuppression, which can increase the burden of pain, discomfort, psychological, and physiological stress⁵

Psychological and emotional impact

HNC treatments mainly cause physical changes which can be chronic. These chronic symptoms can disrupt sleep, which can negatively affect a patient's psychological and emotional well-being.

Anxiety and depression

• Higher prevalence: Due to several factors like the physical, psychological and financial burden of treatment, appearance changes and impaired communication ability
• Sleep disturbances worsen mental health: Poor quality sleep may lead to insomnia, sleep apnea, which can lead to increasingly overwhelming feelings of sadness, irritability, hopelessness, and emotional exhaustion, and mental instability

Body image and self-esteem

HNC treatments often require massive surgeries, which can cause visible changes such as facial disfigurement, scarring, or loss of speech and swallowing functions. These facial changes can profoundly affect a patient’s self-esteem. Many patients can feel embarrassed, ashamed, or experience a loss of identity, which can cause social withdrawal and isolation. For this, even routine activities like eating in public, talking, or looking in the mirror can become sources of distress. 

Cognitive impairment and emotional instability

HNC patients can suffer from poor sleep problems due to various types of conditions before and after treatment. These sleep problems can cause difficulty with memory, concentration and cognitive ability, which can hinder work, relationships, and daily functioning. Poor sleep can also cause difficulties in emotional regulation, increased irritability, frustration, and emotional outbursts.⁷

Assessment and diagnosis of sleep issues in HNC

Tools and methods for evaluating sleep disorders

The sleep disorder assessment uses a tool called polysomnography and physiological methods. Polysomnography helps determine whether a person’s sleep cycle is being disrupted.⁷

Home sleep apnea test

Some people can take a test at home to diagnose sleep apnea. The small device records breathing rate and airflow, oxygen levels, and heart rate. Some tests also give information about blood vessel tone. It assesses the blood vessel muscles. After the test, information can be uploaded to a smartphone app and sent to the sleep medicine specialist for analysis.

Multiple sleep latency test (MSLT)

The subject must be in a quiet, dark room. Four or five naps, split by two hours, are observed. The MSLT records how long it takes the subject to fall asleep.

Maintenance of wakefulness test (MWT)

This test measures daytime alertness. At the time of the test, the patient is placed in a dark and quiet room. Like the MSLT, subjects can take 4 to 5 naps spaced two hours apart, but MWT measures the ability to stay awake during this time. 

Upper airway nerve stimulation therapy evaluation

Patients with obstructive sleep apnea who are unable to tolerate CPAP therapy can be treated with upper airway nerve stimulation. In this procedure, a clinician implants a device that stimulates the hypoglossal nerve to keep the airway open during sleep. To ensure they are appropriate candidates for therapy, patients undergo a BMI examination, a sleep study test, and a drug-induced sleep endoscopy test before the surgical procedure. For some people, this treatment can greatly manage sleep patterns and decrease sleep apnea symptoms. 

Overnight oximetry test 

Overnight oximeters are attached to the finger to detect blood oxygen levels and heart rate throughout the night. Sometimes, sleep apnea may cause drops in oxygen levels while asleep.⁸

Management and interventions

Pharmacologic treatments (e.g., sleep aids, pain control)

• Non-opioid analgesics: Non-Steroidal Anti-Inflammatory Drugs (ibuprofen, naproxen, aceclofenac) are used for mild to moderate pain; Acetaminophen is mostly used alone but can be combined with other agents for more efficiency, depending on the case
• Opioids: Morphine and other opioids. Mostly prescribed for moderate to severe pain
• Adjuvant medications: For neuropathic pain associated with HNC or its treatment, Gabapentin and Pregabalin are effective
• Topical agents: Useful for localised oral mucosal pain, which is associated with cancer, can be treated by topical agents, such as morphine mouthwash, Lidocaine viscous

Sleep aid management

• Benzodiazepines: Promote good sleep and reduce anxiety
• Sedative-hypnotics: Drugs like Zolpidem (Ambien) support sleep initiation
• Antidepressants: Low doses help maintain uninterrupted sleep
• Melatonin receptor agonists: Help regulate circadian rhythm and improve sleep quality

Non-pharmacologic approaches

• Cognitive behavioural therapy: A structured, short-term treatment. CBT typically involves six to eight sessions, conducted weekly. Studies have shown that it can improve sleep in up to 80% of individuals with insomnia and is considered more effective than medication in the long term⁴​
• Sleep hygiene: Mainly associated with habits and practices promoting consistent, high-quality sleep. To maintain a regular sleep pattern schedule, one can create a comfortable environment to sleep in, avoid caffeine and alcohol before bedtime, manage daytime naps, and have fixed hours to go to sleep and to wake up⁴​
• Relaxation techniques: Deep breathing exercises, meditation, guided imagery techniques and progressive muscle relaxation. These also help overcome mental and physical stress⁴​

Summary

HNC patients often experience significant sleep disturbances, including insomnia and obstructive sleep apnea (OSA). OSA generally ranged from 57% to 96% before treatment and 12% to 96% after treatment.⁵ Anatomical changes from tumours and treatments like surgery and radiation are contributing factors, as these result in obstruction of the airway. Psychological distress, such as anxiety and depression, is common among HNC patients and is associated with poor sleep quality.​ These sleep disturbances can negatively impact quality of life, which can subsequently lead to fatigue, mood disorders, and cognitive impairments. Therefore, it is challenging for clinicians to address sleep issues in head and neck cancer patients. For head and neck cancer patients, routine investigations and checkups can help improve sleep patterns and overall well-being.