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Up to 75% of patients with advanced cancer have problems either falling or staying asleep,
with a lesser number meeting the strict criteria for insomnia [90] . In a recent survey, more
than half of surveyed patients report difficulty sleeping, gastrointestinal issues, pain, and
problems with memory, organization, and concentration. Nearly half of patients report hot
flashes, neuropathy, changes in weight, sexual and self-image issues, and emotional upset and
stress [57] .

Not surprisingly, MBC patients also say that living with the disease and undergoing continuous
treatment has a significant impact on quality of life. For most, symptoms and side effects The past 2 decades
of treatment disrupt daily life and interfere with normal activities. As the disease progresses have seen major
and symptoms intensify, treatments become even more disruptive, and emotional distress improvements in
increases. supportive care,
but many MBC
patients fail to
Nearly half of patients say their providers don’t ask them about the symptoms and side effects receive adequate
they are having, leaving it up to them to ask for help when they need it [57, 61] . Yet nearly as many palliation for their
worry about “bothering” their doctors, or express concern about being seen as “complainers,” symptoms that
and are hesitant to bring up their concerns, especially about topics such as emotional distress could improve their
and sexuality. One large survey found that 35% of MBC patients seen in comprehensive quality of life.
cancer centers, and 50% seen in community oncology practices, did not mention sources of
distress to their providers [57, 59, 61] . Clearly, communication difficulties exist on both sides of the
physician–patient relationship.

The past 2 decades have seen major improvements in supportive care, but many MBC patients
fail to receive adequate palliation for their symptoms that could improve their quality of life.
Very few patients are referred to palliative care or pain specialists during their treatment. In fact,
only one quarter of patients are given a symptom checklist as part of their routine office visits,
as recommended by National Comprehensive Cancer Network guidelines [57] .

A common perspective among oncologists is that “managing symptoms to maintain an
optimum quality of life is the major goal of care in the metastatic setting because all therapy is
palliative” [64] . However, the emphasis on palliation as the primary goal in MBC may not conform
to the cancer-controlling strategies many oncologists discuss with their patients, nor may
it reflect patient wishes, as detailed in surveys where MBC patients clearly prioritize remote
chances of treatment efficacy even at the cost of significant toxicity [81] . The dynamic tension
underlying this “treat or palliate” duality of choice runs throughout the literature on metastatic
cancer and plays an important role in disputes about health care policy and allocation of
resources. However, treatment and palliation need not be in conflict but may instead represent
different points on the continuum of care during the course of the disease, driven by the wishes
of an informed patient in consultation with the treatment team.

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