Pain is one of the most common symptoms reported by patients with advanced breast cancer. Bone metastases are the most common cause of pain in this patient group as 70% of breast cancer patients with advanced disease have bone metastases [14]. Approximately 65–75% of patients with bone secondaries suffer from bone pain, and more than half of the patients experience pain during movement, which impair activities in daily living [11, 15]. As metastatic bone destruction progresses, the increasing incidence of pathological fractures, spinal cord compression and malignant hypercalcaemia further increases suffering [14–17]. Pain arising from non-osseous metastases is also common and may include chest pain related to pleural or lung metastases, abdominal pain due to peritoneal carcinomatosis, pain due to liver capsule stretching, bowel dysfunction, headache caused by brain metastases or pain related to loco-regionally advanced breast cancer or skin metastases.

Lung metastases and pleural effusion cause dyspnoea, which is a very distressing symptom. In addition to dyspnoea, cough and chest discomfort are common concerns for these patients. In cases of bronchial obstruction or haemoptysis, palliative radiotherapy is effective [25]. Like in the treatment of bone metastases, a single fraction alleviates symptoms as effectively as multiple fraction radiotherapy. Treatment of symptomatic pleural effusion by thoracocentesis either with needle aspiration (approximately 1000 ml each time) or catheter drainage (using an indwelling catheter system) gives rapid relief of dyspnoea and discomfort. Pleurodesis, thoracoscopy and injecting talc into the pleural cavity (talc poudrage) appeared to be effective in preventing fluid build-up [26].

Opioids are effective in alleviation of dyspnoea [27, 28]. For opioid-naive patients, starting with 2.5–5 mg of oral short-acting morphine for rescue medication is recommended. If more than 2–3 daily doses are needed, a low dose of long-acting opioids for regular use can be considered especially in patients with persistent dyspnoea. Opioids are also effective in the treatment of a dry cough resulting from airway irritation.

Loco-regionally advanced breast cancer with skin metastases may cause severe and distressing symptoms significantly impairing body image and social life. Lymphoedema of the upper extremity and chest wall, skin ulceration, bleeding, pruritus, exudate, infection, odour and pain may be extremely distressing. With limited disease surgery, radiotherapy or electrochemotherapy is effective especially with stable systemic disease, but with extensive progressive disease, they are seldom possible [29]. Palliative care with careful wound care is needed [30]. For bleeding either systemic or local tranexamic acid or an adrenalin dressing can be used. Single-fraction radiotherapy is also used to control bleeding. Systemic or topical antibiotics (e.g. metronidazole) in addition to odour-reducing (charcoal) dressings may be used to reduce unpleasant smells. Modified supportive bandaging, support and positioning a paralysed swollen arm, passive movements and gentle massage can comfort lymphoedema [31].

One third of women with metastatic breast cancer develop brain metastases during the course of their illness, less commonly leptomeningeal metastases [32]. The prognosis of brain metastases varies depending on the histopathology of the disease, the extent of and stability of extracranial disease and whether there are solitary or multiple brain metastases. In the palliative stage of the disease, the prognoses are usually poor. Palliative radiotherapy is recommended for patients with two or more months of life expectancy. In the end-of-life situation, the symptoms caused by brain metastases are alleviated by corticosteroids and convulsions by antiepileptics and benzodiazepines. Treatment options for cerebral metastases are dealt with more fully in ► Chap. 54.

Liver metastases, without symptoms of liver failure, are mainly asymptomatic. Pain may be caused by an enlarged liver causing stretching of the liver capsule. This may be alleviated by corticosteroids. Lobular carcinoma in particular may spread to the peritoneum and even invade the viscera (stomach, bowel, bladder) and cause bowel dysfunction and ascites formation. In addition, ascites may be related to liver metastases and liver failure. Abdominal paracentesis (3–6 l /day) affords rapid symptom relief. For patients with high volume and rapid formation of ascites, a tunnelled catheter can be used. However, tiredness, hyponatraemia and a progressive fall in plasma albumin have been reported after repeated paracentesis. The role of diuretics in the treatment of malignant ascites is controversial, and they are not routinely used. Bowel obstruction and paralysis (ileus) caused by peritoneal carcinomatosis are a severe and very distressing symptom. If not operable, the prognosis is poor, at only a few months. As the obstruction is rarely total, the symptoms can be alleviated with antisecretory agents (somatostatin analogues such as octreotide, anticholinergic agents like glycopyrrolate and butylbromide), opioids and antiemetics via subcutaneous infusions to reduce bowel secretion, pain and nausea/vomiting [33]. After vomiting has been reduced, the nasogastric tube can be removed, and patient can take some food and liquids orally with small portions, which significantly improves the quality of life of dying patients and makes care at home possible. In a case of severe vomiting, percutaneous gastrostomy might be needed to alleviate vomiting.

Fatigue, insomnia, depression and anxiety impact negatively on patients’ daily lives and emotional well-being. Fatigue is the most common symptom of advanced cancer, reported by three quarters of patients and subjectively is the most disturbing [8, 11–13, 34]. It is an activity-limiting symptom that significantly affects functional capacity and interferes with role functioning and ability to conduct daily activities [34, 35]. It may begin with a simple decrease in physical activity, but can cause feelings of loss of control, loneliness and isolation [36]. Significant fatigue is associated with higher level of depression, pain and sleep disturbance forming a symptom cluster negatively affecting to QoL [35, 37]. The prevalence of depression and anxiety among breast cancer patients with metastatic disease is higher (up to 40%) than the prevalence within patients with early-stage disease (26%) [11, 34, 38, 39]. Insomnia is also a common problem among cancer patients. 40–60% of patients with advanced breast cancer report sleep disturbances, in one third of them moderate or severe [8, 11, 12].

There is an increased need for psychosocial support of breast cancer patients throughout the disease trajectory. The diagnosis of metastatic disease with limited life expectancy represents a time of shock, crisis and anxiety for patients and their families. There is an ongoing need for repeated, truthful but sensitive discussion and information provision about their disease. Emotional distress should be systematically assessed. Visual analogue tools such as the distress thermometer can be used to screen patients and identify those with the utmost need for psychosocial counselling and support. A scale of four or more out of ten compares well with other multiple item scales. Accompanying problem lists help to identify distress from emotional, spiritual or religious concerns, social or family issues or physical problems. Especially vulnerable are young women and women with small children or adolescents. Psychosocial support delivered by professionals and peer support from patient groups may help women discuss their experiences and improve their emotional well-being particularly in those women who are more distressed [40]. Also families are profoundly influenced by incurable malignant disease of a family member. Terminal illness alters daily life, roles and relationships within the family. Additional worries arise regarding how the family will cope after the death of the patient [41]. Thus, psychosocial support may also be helpful for family members and caregivers.