Pharmacologic management of postoperative sleep disturbance in breast cancer

Postoperative sleep disturbance (PSD) is a common yet underrecognized complication after breast cancer surgery and is associated with pain, fatigue, affective symptoms, impaired quality of life, and delayed postoperative recovery. Its management remains challenging because symptom presentations are clinically heterogeneous, and treatment decisions must balance therapeutic efficacy with safety within the broader context of breast cancer care and survivorship. This narrative review summarizes the current evidence on PSD after breast cancer surgery, with particular emphasis on pharmacologic management, therapeutic positioning, and breast cancer-specific safety considerations. Available evidence suggests that a phenotype-guided pharmacologic management framework may be clinically useful, although this approach remains conceptual and has not yet been prospectively validated in postoperative breast cancer populations. Short-course hypnotics may be considered for acute insomnia characterized by prominent nocturnal hyperarousal, whereas melatonin and melatonin receptor agonists may be particularly relevant when circadian disruption predominates. In contrast, gabapentinoids and multimodal analgesic strategies may be more appropriate for pain-dominant or mixed symptom presentations. Across drug classes, treatment selection should account for cumulative sedative burden, respiratory risk associated with concurrent opioid use, next-day cognitive adverse effects, and endocrine therapy context, including avoidance of strong CYP2D6 inhibitors in patients receiving tamoxifen. Among non-pharmacologic interventions, cognitive behavioral therapy for insomnia (CBT-I) is best positioned as the leading adjunctive strategy, particularly for persistent symptoms or during medication de-escalation. Bright light therapy, exercise-based rehabilitation, mindfulness-based interventions, and acupuncture may provide selective supportive benefits in appropriately selected patients, although their roles are generally complementary rather than primary. Overall, PSD after breast cancer surgery should be recognized as a clinically meaningful component of postoperative recovery and survivorship care. Future studies should prioritize standardized sleep outcomes, objective monitoring where feasible, clearer phenotype definition, and integrated efficacy-safety assessment to support more individualized and mechanism-informed management.