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In examining different coping strategies, studies indicate that patients’ attempts to cope by
avoidance turn out to be far more distressing than direct and active discussion and problem solving,
a finding in many serious diseases [47] .

Numerous studies have found that better emotional functioning is strongly linked with fewer
physical symptoms [48-52] . These multiple symptoms interact with one another in unknown ways.
As one notable example, 56 consecutive newly diagnosed MBC patients in one hospital-based
study [51] , when scored for health-related quality of life and coping capacity using a series of validated
measures, reported “multiple, concurrent and interrelated” symptoms, with two thirds reporting 10
to 23 symptoms. In another study, clusters of symptoms tended to be associated with one another:
for example, fatigue, drowsiness, nausea, decreased appetite, and breathlessness [53] .

Adjustment to illness, write Brennan et al. [54] , involves “ongoing psychological processes that
Access to mental occur over time as the individual, and the individuals in their social world, manage, learn from, and
health services is often adapt to the multitude of changes which have been precipitated by the illness and its treatment.”
either lacking or is not Fortunately, many patients and families become quite knowledgeable about MBC and how to
pursued by patients live with the disease. Time passing since recurrence or diagnosis can moderate psychosocial
who could benefit.
distress [55] . Coping and adjustment are extremely complex processes, however, and not all MBC
patients are equally resilient.

Longer-term adaptation after MBC diagnosis has not been widely studied. However, in 1 survey,
nearly half of patients with HER2+ breast cancer surviving more than 6 years after MBC diagnosis still
reported symptoms of anxiety and depression, despite decreased physical symptoms [56] .

In surveys, most patients’ overall satisfaction with their HCPs is good, and they generally believe
they are coping well despite the challenges they face [57, 58, 60] . They attribute the coping to their own
resilience and spiritual beliefs and to the kindness and generosity of others [61] . A number of small
qualitative studies across diverse socioeconomic and racial populations of women with MBC have
reported that maintaining hope is a critical factor in coping [62] .

Psychiatrist David Kissane describes the challenge of living with MBC as a confrontation of
Emotional distress existential suffering [63] . Feelings of hopelessness and futility, loss of faith and transcendence,
tends to worsen with loneliness, shame, fear of dependency, profound sadness, and death anxiety are all part of a
disease progression, universal and fundamentally human struggle as patients deal with their mortality. Each challenge
as symptoms and contains within it the seeds of transformation and adaptive adjustment. And “physicians can do
side effects increase. much,” says Kissane, “to nurture courage and maintain each person’s sense of meaning, value, and
purpose.”

In conclusion, interventions for anxiety and depression in MBC patients represent a crucial
service that health care workers can add to the patients’ and families’ own set of coping tools.
Appropriate referrals to mental health professionals, for medical and nonmedical treatment
and other interventions, are important, whether the referral is for pharmacological, behavioral,
or psychological intervention or some combination thereof. An extensive literature exists on the
efficacy of various methods of helping cancer patients confront psychosocial issues, symptoms
of disease, and side effects of treatment. Sources of emotional support, individual and group
psychotherapy and counseling, as well as adequate information about the disease, its treatments,
and methods to alleviate symptoms and side effects have all been shown to be useful in helping
patients to cope with and adapt to their disease [64] .
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