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"Medical Journeys" is a set of clinical resources reviewed by physicians, meant for the medical team as well as the patients they serve. Each episode of this journey through a disease state contains both a physician guide and a downloadable/printable patient resource. "Medical Journeys" chart a path each step of the way for physicians and patients and provide continual resources and support, as the caregiver team navigates the course of a disease.

Palliative care services in patients with breast cancer aim to improve quality of life for the person with breast cancer. Patients with advanced and/or metastatic breast cancer have particularly that must be addressed in order to minimize severe distress and pain and optimize symptoms and quality of life as much as possible.

Palliative care is not the same as hospice care. While there is overlap, hospice care provides support and care that is provided for people who are nearing -- usually within 6 months -- the end of life.

Although palliative and hospice care both focus on improving quality of life, patients receiving palliative care services can remain on active treatment.

Multidisciplinary Team Is Key

Many different members of a care team work together to provide palliative care. This can include a primary care provider, oncologist, radiation oncologist, palliative care physician, nurses, registered dietitian, pharmacist, psychologist, social worker, and others.

It is important to inform patients that they can receive palliative care during their treatment, from the time of diagnosis to end of life.

Patients who received alongside treatment for metastatic breast cancer have reported less severe symptoms, better quality of life, and greater satisfaction with treatment.

Metastatic Disease Progression

The progression of metastatic breast cancer varies among individuals, so patients will typically experience acute and stable phases at different times. At some juncture, the options for metastatic breast cancer treatment become limited. When this happens, shared decision-making should be used to determine if the patient wishes to , and focus on palliative and supportive care.

Progression can be classified into :

• Smoldering: Very slow progression; patients are often asymptomatic. Survival is typically classified in terms of years and in some cases, over 10 years

• Gradual: Gradual progression of the disease over time, with increasing symptoms and rate of progression

• Rapid: Rapid progression, with severe symptoms and typically characterized by a prognosis of several months

• De novo poor condition: A person in poor general health when diagnosed with breast cancer

Bone is one of the in metastatic breast cancer. More than half of patients with metastatic breast cancer will develop metastases to bone.

Patients with breast cancer and bone metastases should be treated with bone-modifying agents and options include zoledronic acid, pamidronate or denosumab. These medications can reduce bone complications and bone pain caused by bone .

Therapeutic Approaches

Palliative radiation therapy may be used to caused by metastatic breast cancer, and can target specific areas where the cancer has spread, such as bones or soft tissues.

can sometimes help to alleviate pain and improve mobility for those whose cancer has spread to the bones.

Surgical removal of metastatic tumors may be indicated when the tumor is causing an obstruction or bleeding.

Nerve block procedures can be performed to manage pain caused by nerve compression or invasion by cancer.

If metastatic disease has caused ascites or pleural effusion, procedures such as paracentesis or thoracentesis, respectively, can be performed to drain excess fluid and provide symptomatic relief.

Pain Management

Over-the-counter such as aspirin, ibuprofen, acetaminophen, and naproxen are typically used to treat mild to moderate pain.

Opioid medicines, either in , can be used to treat moderate-to-severe pain. Immediate-release forms are most often employed to treat sudden or breakthrough pain.

Careful routine pain assessments, as well as physical and psychological evaluations of the person with metastatic breast cancer, are the cornerstones of breast cancer pain management.

Complementary or integrative medicine approaches such as acupuncture, massage, or hypnosis, are options for pain management and can be combined with standard medical .

Fatigue

According to the National Comprehensive Cancer Network (), cancer-related fatigue is a persistent, subjective sense of physical, emotional, and/or cognitive tiredness or exhaustion related to cancer or cancer treatment that is not proportional to recent activity and that interferes with usual functioning.

Treating , such as pain, can help ease cancer fatigue. Complementary or integrative medicine approaches may also help with the management of fatigue.

There is to support pharmacological treatments in cancer-related fatigue. NCCN guidelines state that methylphenidate and shorter courses of corticosteroids can be considered for cancer-related fatigue in end-of-life management.

Dyspnea

The management of dyspnea, a among patients with metastatic breast cancer, includes treatment of underlying conditions, including but not limited to the presence of lung metastases, infections, anemia, drug toxicities, pulmonary embolus, and airway obstruction.

Distress and Anxiety

NCCN as a "multifactorial unpleasant experience of a psychologic (cognitive, behavioral, and emotional), social, spiritual, and/or physical nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment."

Management of distress for people with breast cancer, according to NCCN guidelines, should include routine and regular screening using tools such as the . This tool asks the patient to rate their extent of distress in the past week, on a 1-10 scale, of practical, family, emotional, physical problems, and spiritual or religious concerns.

If indicated, patients may then be referred to , social workers, or chaplains for further counseling.

Advance Care Planning, End-of-Life Care

Advance care planning is a process of communication between the person with metastatic breast cancer, their family and loved ones, and their healthcare team.

Research has shown that people with metastatic breast cancer -- and patients with advanced disease in general, along with family members and providers -- consider these to end-of-life care:

• Managing physical symptoms

• Avoiding a useless prolongation of dying

• Having good self-esteem

• Relieving burden on family or caregivers

• Deepening ties with loved ones

Advance care planning should be regarded as a to improve the quality of life of people with metastatic breast cancer.

Physicians should be prepared to , including hospice and emotional support specialists, to help patients make informed decisions about their care.

Read previous installments in this series:

Part 1: Breast Cancer -- The Basics of Diagnosis, Staging, and Treatment

Part 2: Breast Cancer: Making the Diagnosis With Breast Biopsy

Part 3: What to Know About Management of Early-Stage Breast Cancer

Part 4: New Treatment Options for Locally Advanced and Metastatic Breast Cancer

Part 5: Genetic Testing in Breast Cancer: Mutations, Multigene Panels, and More

Part 6: Case Study: Older Male With Rash, Chest Swelling, and Mysterious Skin Issues