hope means different things to different people depending on your situation.

And certainly in the time that I've been in my role at Breast Cancer Now, things have changed. You mentioned about 50 years ago, things being different. I've been in this role 12 years, I think now, and things have changed phenomenally, just in that shorter space of time.

Welcome to the Breast Cancer Now podcast, providing support and information to anyone affected by breast cancer. This podcast contains the personal stories, opinions and experiences of its speakers rather than those of Breast Cancer Now.

Today we're talking about metastatic or secondary breast cancer, which is when the cancer spreads beyond the breast and becomes incurable. Our guest is one of Breast Cancer Now's senior clinical nurses, Catherine Priestley. Some of you may remember Catherine previously came on the podcast with patient Paula Van Santen to talk about metastatic breast cancer. But today she has the sofa all to herself and we're going to go into a little bit more detail about what this stage of disease is and what it means. And because I've been living with metastatic breast cancer myself for four years, we're going to make this more of a discussion. So Catherine might ask me a few questions about my own diagnosis and treatment and how I found hope over the years.

Catherine, welcome back to the podcast.

Laura, thank you for having me.

So this is the Breast Cancer Now podcast. So let's get to know each other with a few warm-up questions all related to the word now.

If money was no object and you could go anywhere in the world on holiday or even to live, where would you go right now?

Right now, two different answers, but on holiday to Australia, really want to go to Australia. But if I was to go somewhere to live, I've been yearning to go and live in France. I love France.

Nice.

Complete the sentence. Right now I am...

Really warm.

Complete the sentence. Right now I want...

A very cold drink.

And I will never...

I will never give up on the people that I think need me or want me for support. I will always be there for them.

Love that. Well, that is, think, the definition of a nurse and it's the definition of the Breast Cancer Now nurses.

So first things first, what is metastatic breast cancer?

So metastatic breast cancer, and you mentioned the word secondary as well. has got different names. So we use metastatic, we use secondary, we use advanced, mets, stage 4, is when breast cancer that started in the breast has moved beyond the breast or the lymph nodes underneath the arm. So we call that part of the body, the axilla, the armpit. It quite often goes to places like the bones, the lungs, the liver. For some people, goes into their tummy, their abdomen. or even into the brain or lymph nodes that are in the rest of the body as well. And we know that when breast cancer has spread to those places, when it's become metastatic, where the word metastasis or metastatic, metastatic comes from, then it can no longer be cured.

And can I ask you, this may be a bit technical, but how does it get to those places? Does it go through the blood or how does it travel?

Yeah. So, Cells from the actual cancer itself, from the tumour, are able to get into the lymph system. So that's a system that takes away waste products from the tissues, as well as the blood system, which you've just mentioned. And that enables those cancer cells to travel around the body. Now your lymph nodes, which are actually a really key part of the process of... checking out and getting results and getting the whole picture of a breast cancer diagnosis are there to actually catch some of those cancer cells. So they act like sieves if you like, but sometimes it's still possible for those cancer cells to go beyond lymph nodes and round the body as they are in the blood circulation as well.

And by moving round the body, what they can do is lodge themselves in particular areas, as I've already mentioned, and then set up new breast cancers there, new secondary breast cancer. So secondary breast cancer or metastatic breast cancer that is in the liver is metastatic breast cancer. It's still in the liver. It's not liver cancer and the same with the bone and the same with the lung. So it's breast cancer that has spread to those places rather than being something that has started in those places, if that makes sense. in, so in my case, I had breast cancer in my breast in 2012 and at that time it was not in my lymph nodes. But then 10 years later, I got metastatic cancer in the bone, which is breast cancer that had spread to the bone. Does that mean that it went through my lymph nodes at some point or is there, can it bypass the lymph nodes?

Well, it can travel in those two, by those two means that I've already said. So maybe it did actually manage to get into the blood vessels. There are blood vessels in and around the cancer. So those cancer cells as said before, can get into the blood system or it may well have gone into the lymph system. It's just not been picked up in the way that we would normally pick that up. And that unfortunately does happen in about 20 % of people who have a breast cancer removed from the breast or the chest area. Then you will find that there is definitely cancer in the lymph nodes underneath the arm. And for a lot of people, the rest of people, then they don't have that. But that doesn't mean to say it absolutely hasn't. Not one cell has escaped that. And also, you know, when the tissue is looked in the lab, then they will look for something called lymphovascular invasion. So that's whether it has invaded and it is into the lymph system and there's good evidence of that, or whether there was any evidence of any blood vessels being permeated by those cells. That's a guide, but it's not an absolute guarantee, unfortunately. So there are quite a lot of people out there who will say, I don't understand how this has happened. There was nothing in my lymph nodes. There was nothing to suggest any spread. And yet here I am with this diagnosis of metastatic breast cancer.

And what about the word terminal? Cause sometimes that has a slightly different meaning. And I know we tend not to use that word, particularly not a Breast Cancer Now, but it is what you often see in the news headlines, for example.

Yeah. The media and maybe the public at large use that when you hear somebody say, Oh, I've got a friend and she's got this diagnosis, it's terminal. And what they mean by that is it can't be cured as nurses, as doctors. anybody in the medical field will really think about the terminal phase of life of being the last weeks or maybe even a few months of life. So we see that quite differently. I understand totally where the public and the media are coming from, but it's quite alarming. And particularly when we think about the fact that, you know, people like you and lots of other people are living much, much longer. So it's quite right to separate that out if we can.

That's definitely my understanding of it is, you know, 50 years ago with this diagnosis, my diagnosis might have been terminal because there were not enough treatments to keep me alive for years. But right now I don't see myself as having a terminal illness because I think I'm still going to be here for quite a while. So it just doesn't feel right, especially as I'm here and I'm well. know, so I think, yeah, only referring to terminal, perhaps when you've finished all. or treatment options maybe makes more sense.

Yeah, exactly. And there are plenty of people like you out there, as you've just said, that don't feel that word applies to them. They are out there. They are living with the impact of their disease for sure, but they're also living, travelling, working and enjoying the things that they get most out of life. So, you know, that word just simply doesn't exist in their vocabulary. So we need to use it carefully. Yeah.

There are two different ways we can... be diagnosed with metastatic breast cancer. One is like in my case, where you have breast cancer and then years or months later or even decades later for some people, it spreads and becomes incurable. But there's another term we use, which is called de novo. What does that mean?

Okay. So obviously you've said that the first way is that somebody has had a primary breast cancer diagnosis. We've just touched on the way that breast cancer can spread to the other parts of the body. Sometimes that happens quite quickly for people, sometimes that takes quite some time. We know that and we've discovered, royal we, scientists have discovered that actually breast cancer cells can lie dormant for quite some time. So it's not just about how they spread, but where they spread to and the environment they decide to put themselves in or stay in and something about that environment that switches them on.

De novo metastatic breast cancer means new basically. So it means that it's been found at a similar time or at the same time. So some people will present with symptoms of metastatic breast cancer, be that pain in the bones, be that problems with their lungs, with breathing, pain in their abdomen, that sort of thing. And it's that's found first and then they realise that they've got breast cancer in the liver, in the bones, and then need to go and search in the breast. For some people, they get a diagnosis of primary breast cancer. And it looks as if they need to have some more tests to see how far or if that breast cancer has spread. And yes, the tests come back and their scans come back to show that it has already spread. So it can be both ways round, but essentially it's at the same time or within a few weeks or months of.

So it's a double whammy if you've got breast cancer. it's already spread, but that doesn't necessarily mean that the treatment options are that much worse. There are lots of people diagnosed with de novo breast cancer who fortunately can get treatment that can keep them going for years and can really shrink the cancer. exactly. So the same principles of treatment would apply for oncologists who are looking at that individual. They've not actually had any cancer treatment prior to that, which sometimes can influence what the cells look like. how they've developed, how they've developed to try and stay strong and stay in the body. So sometimes people with de novo metastatic breast cancer can see that they have a really good response to treatment, which is really encouraging. I know that doesn't necessarily apply to everybody, but of course what they haven't had is that prior knowledge and that prior experience of a primary breast cancer. Some might argue that's a good thing. You know, I've just said about treatment, also, you know, drawing those reserves and thinking about what's helped and what experience you've had in the past for some people can also be helpful. that double whammy definitely applies to an awful lot of people in that situation. Psychologically, very, very, very hard. Such a huge shock.

For those listening to this podcast who have had breast cancer, primary breast cancer in the past. and want to be aware of the signs and symptoms of the cancer spreading, what should they be looking out for?

I mean, it's a really sort of difficult subject, isn't it? Recurrence. People are really worried about that. They may not feel that they've been given an awful lot of information about recurrence and what to look out for. But knowing is power. you know, I've mentioned the places that metastatic breast cancer typically spreads to. So if we think from the top to the bottom of the body, then things like headaches, dizziness, nausea, a bit of confusion might denote that somebody's got some brain mets. Thinking about the lungs, then they might get a bit breathless when they're going upstairs or, you know, out of ordinary sort of breathlessness when they're doing things that they can normally do. They might have a cough. They might have a little bit of hoarseness sometimes as well.

In the liver, then people might feel quite full, they might get a feeling of fullness underneath their ribs, they might get shoulder pain, they might get hiccups, they might get a feeling of nausea and particularly fatigue I think when the liver is affected as well. If you've had lobular breast cancer then it's also important to remember that type of breast cancer can spread to the abdomen in and around the gut. I don't want to make it exclusive because we can never say that other types of breast cancer like the ductal breast cancer will never go there. So I think it's important that people know everything. But lobular breast cancers do spread to the abdomen. So feeling sickly, feeling as if you're full quite quickly, needing to go to the toilet to pass urine quite frequently. Those sorts of signs are something to take note of as well.

And then thinking about the bones as well, pain. So pain, not just joint pain and of course there's loads of the treatments that give all of these types of side effects or symptoms, you don't know which they are. But bone pain that happens, which is possibly worse on a night and really gives you, it's that gnawing sort of type pain and people sometimes actually experiencing fractures or if they've got... bone metastasis in their spine, they might even find that their spine starts to crumble and starts to nip the spinal cord. So they might get tingling in their fingers, in their feet. So all of those things sound really scary, but they're all important changes to be aware of so that if you have that power, you have that knowledge, you can tell somebody about it and make sure that they check that out for you.

Now, every single thing that you just mentioned, also has another explanation. So for example, I get headaches and nausea, which are migraines. I get joint pains or bone pains, which are due to all the medications that I'm taking. get feel bloated all the time because I might have just eaten some butter beans or sweet potato or something. So there's always explanation. So you don't necessarily have to jump to the conclusion that your cancer has spread to your brain. Where do we, and I think that's a really, really hard thing when you have had primary breast cancer and you're perhaps years or months away from it and you start to worry about every single thing. You know, if you get more than a couple of headaches, you start to think, oh my God, has the cancer spread to my brain? How do we figure out what is worth worrying about and what is just a normal thing that we can pass off as normal?

Yeah. There isn't a magic bullet to sort of the answer to that. One's one thing, one's definitely the other thing. I think if it's new, it's persistent and it's not usual for you. So if it's two, two, two and a half, three weeks down the line and it's not getting better, it's not gone away. It is absolutely nothing that you've, you've done. You've not been digging in the garden. If you've got back pain, those sorts of things, then it's absolutely right to be able to, you know, to tell somebody about that. It is frightening and it's worrying and we get loads of helpline calls so that people that call our helpline talk to our nurses that they're worried in case that might be whatever symptom it is. might be a sign of metastatic breast cancer, but it is really important to get that checked out.

And I guess it is that balancing that hope against the reality, having the knowledge that you need to just keep an eye and be body aware and just listen to your body, what it's doing and how long symptoms have been around for. And also the hope and the knowledge that, you know, hopefully the treatment that you've had was given with curative intent and hopefully that's what's going to happen. but having that balance is really difficult. And I guess that must have been sort of similar for you. know your symptoms and your story about your development of breast cancer went not along dissimilar lines, but sometimes it can take a little bit of checking out and getting to it, get a diagnosis. Was that what it was like?

Yeah, so I had my breast cancer spread after nine to 10 years to my sternum bone and I... looked at those symptoms that you've mentioned quite a lot and I found it really hard to know what was bone pain and what bone pain felt like and you read the descriptions and you think, well, I don't know if that is what I've got. It wasn't necessarily worse at night or it wasn't necessarily worse lying down and you just mentioned annoying pain, but I don't know what, I really don't know what that means. And I sometimes find it really hard to describe what I'm feeling, which is so individual to me.

But I had a real tenderness on my skin above my sternum bone. if, if someone, sometimes if someone would hug me, it would really hurt and it was sort of smart. And that wasn't described in the, you know, in the description of what it feels like to have bone pain. And then I went to the doctors and it was kind of passed off as costochondritis, which is an inflammation around the ribs. and I did a lot of exercise and I also had some breast soreness and I found it really hard to figure out what was what or whether it was worth worrying about. But I think as you said, it was new and it continued and it continued and it continued. And I think that was the thing for me that was the confirmation that this was something to worry about. What I found find really helpful is keeping a daily diary on my phone of notes of all the symptoms and things that I feel. So I've done this for years and it was really helpful when I had that bone pain because I could go, when I went to the hospital, I could go back and see how long I'd been feeling those symptoms for and what I'd written on certain days. So for example, I'd written things like went swimming and felt like my bones were crunching together when I did front crawl and I couldn't push myself out of the pool. And that was in the very latest stages of it just before diagnosis, but I could tell that it was getting worse. having, but having those notes really helped to reassure me that I wasn't inventing or exaggerating these symptoms. They were really getting worse. So I think particularly if you've got memory problems, that is a really good one to do.

Yeah, and all of those things that I said, you know, there are typical ways of describing things, but there are always going to be nuances and sort of subtle differences to those as well. But I think writing that down is a really good idea, particularly if you're not really sure what it feels like, whether it's consistent, is think to yourself every day. Can I write that down in a book on your phone, like you say, and then you might see the consistency in it. And you've got then something tangible to put in front of a health care professional, whoever it is, and said, see, this is how it's been for me over the last two or three weeks or. however long that is and present that to them. So they've got it actually a bit bigger, fuller picture maybe of how it's been and how it's been impacting you.

Yeah. And when we talk about when you haven't had breast cancer, we encourage people to check themselves regularly, check your chest and check your armpits for lumps and changes and puckering leakage, that kind of thing. Can we check ourselves in the same way? for metastatic breast cancer or is it more of a just a general body awareness?

I think the way we describe it is general body awareness but I suppose it is that self scan isn't it? I've never really thought about it in the sense of doing it in the same way as a breast awareness. We don't necessarily these days talk about breast checking from a monthly or a timely perspective. It really is something that happens all of the time, but something that is consistent, not necessarily on a named day of the month, that type of thing. But I guess as somebody that's had a breast cancer diagnosis or a cancer diagnosis of any description, more acutely aware of what they're doing. And, you know, I don't need to tell you that any ache or pain. you that happens, you automatically think, this to do with the breast cancer? Is this something even now, has it spread? it, you know, has it gone somewhere else? Has something got bigger, you know, depending on your situation?

So I guess that sort of self-scan type thing fits in here just so that people are aware of their bodies, you know, and whether that is something to do with headaches or whether that is something to do with... I do actually find it a little bit more difficult going up these stairs these days. I don't remember when that started to happen, but it is happening. So that type of thing. again, balancing it with the things and the changes that you know potentially can happen, but also things that might be not on the list that I've already given you or is written down in the information that's on our website or in our publications and just having the knowledge that and that just having that sitting by.

It's really easy for me to sit here and say that. and really tricky to have that in mind, but also not let it take over your life and be obsessive about. And I don't mean that in a derogatory way. I just mean not letting it take over your life, letting you check in with your body, tune into what's happening and then tuning back out again, if you possibly can. And if really is taking up space in your mind, then that's time to get some help with managing that. Cause we can't take that anxiety away. We can't tell anybody how to feel. or not to worry, but it's about how you manage that anxiety as well. So I suppose there's the checking in bit and being realistic, but there's also the managing the worry if you're finding it's taking over as well.

So if you are experiencing signs and symptoms, what should your next steps be?

So that depends on whereabouts you are, how long after your treatment, your diagnosis and your treatment is. And most of the people that we speak to are able to get back. They've probably got something called open follow-up, which means that they can go back to their breast care nurse, they can go back to their treatment team to report signs and symptoms. And I know that they're all absolutely maxed out there, but they are there to be able to report that to and however busy they are. Most nurses that I speak to, I don't think I speak to anybody that says I don't want to know about this. I'd rather my patient tell me about something that's worrying them, that's concerning them, that is a new and persistent symptom so that we can get them in to check that out.

The other side of that, of the other opportunity, if you're a long, long time and not in contact with your treatment team, because it's such a long time since you completed treatment, is going to your GP. And we know through the work that we've done at Breast Cancer Now that can sometimes be a little bit tricky, that some GPs don't automatically sort of red flag the fact that somebody's had a primary breast cancer beforehand. So, you know, it is again, it's a bit of empowerment about saying, I know that these sorts of signs and symptoms are the things I need to be looking for, the changes I've been told to look for. I'm reporting it to you and remember I had a primary breast cancer. you know, what I want to do is try and rule this out. So it's ruling it out rather than ruling it in.

Sometimes that takes a little bit of persuasion. But again, we're working on that to make sure that health care professionals, whoever they are that people come in contact with, that they talk about those signs and symptoms will take those seriously. and check them out or at least monitor them until they, know, just to see if they need checking out within a specific timeframe, that type of thing.

I know I had the open access phone line at my hospital in between primary and secondary breast cancer and I called them often with my concerns and they were absolutely brilliant. I would speak to, sometimes it was the same nurse, sometimes it was a different one, but I sort of got to know the names and would call them often crying and say, I've got this. problem, I'm thinking it might be metastatic breast cancer, what should I do? And they would sort of reassure me as to whether it was worth me coming in for a scan or whether it was one that I could just leave for a few weeks and see what happens with it. So they were brilliant.

And also another time when I was worried about the symptoms of metastatic breast cancer, my local GP, I went to her and I said, look, I think this is metastatic breast cancer. She said, yeah, I'm going to send you, refer you back to your hospital and just having that knowledge and bringing up that flagging the fact that you have had breast cancer is really important because those GPs are so busy, they might not necessarily have read back all your notes, especially if your breast cancer was a really long time ago. So you going in there and saying, hey, I've got new headaches, I have had breast cancer in the past is going to be really helpful, I think.

If you are diagnosed with metastatic breast cancer, what are the next steps then in terms of treatment?

So we know, I've said before, metastatic breast cancer cannot be cured, but it is, and these days it's been treating more successfully. And by that, I mean keeping it under control. So that's the aim of treatment for metastatic breast cancer is keeping it under control. Whether that is that the disease stays static and nothing gets any spreads any further, nothing gets bigger or whether it is for a lot of people these days they do talk about the fact that their disease starts to disappear and for a lot of people in subsequent scans after they've had a few months of treatment that their disease disappears but the principle is treating the whole body because it's spread through the blood system, because it's spread through the lymphatic system it could literally be anywhere in the body we've talked about the typical sites but it could be elsewhere so it's really important that systemic anti-cancer therapy is used.

And that comes in different formats depending on the biology of the cancer cells that we're talking about. So there's a full picture to be established by the treatment team. So, you know, if somebody has a biopsy or they have a scan that tells them the result says, yeah, this is metastatic breast cancer. then there will be a little bit more work to do and that can be worrying because once you know that diagnosis, of course, you know, life is absolutely changed. It's turned upside down in one sentence. Then that news really does rip through, you know, how you're feeling and what that means for your future. But it is important to take a little bit of time to take stock, to do a bit more work, to get that full picture so that the right treatment can be planned.

And as you said, things have changed for a lot of people, not everybody unfortunately but things have changed for a lot of people whereby their treatment is really successful and they remain on treatment and the same treatment for a number of years. So it's not unusual these days for us to find people that have been living with their metastatic breast cancer for a decade or more than a decade these days. we know that systemic anti-cancer therapy can be really successful. It is about finding out what you need to do, planning the right treatment, monitoring that treatment, taking into consideration, you know, the person that you've got in front of you as the patient, as that person, the whole person in front of you and their wishes and their goals and talking and working together for that treatment plan.

You mentioned that people can live for potentially decades. We did just have Laura Ashurst on this podcast. who has been living with secondary or metastatic breast cancer for 18, 19 years now. So she is an outlier, you know, that's not the norm. hearing stories like that really do give you hope. So I think it's important to mention and her episode is a great one. So I do recommend you listen to that. mean, hope is absolutely one part of that reality and hope sort of. Seesaw, it's really important. Hope means different things to different people depending on your situation. But the fact that there are people out there like yourself and then also going to sort of people like Laura that have been managing to live with their disease, which you don't have any control over, that's perfectly, yeah, it's true and it's reasonable that people would worry that's not going to be them. That doesn't take away the worry about things. it's good to have something to think, actually there is that hope there. They are, you know, they are actually a beacon of that hope.

And certainly in the time that I've been in my role at Breast Cancer Now, things have changed. You mentioned about 50 years ago, things being different. I've been in this role over a decade, 12 years, I think now, and things have changed phenomenally, just in that shorter space of time.

We'll go back to talking about the different treatment options in a moment, but first, I wanted to just talk about the emotional impact because when you get that diagnosis, it is like the world has ended. You know, I still remember the hot summer of 2022 when I found out my breast cancer was definitely back and it was just devastating and it affects you. Obviously it affects you forever. Still now for me, but not in the same way it did then. And that was such strong levels of grief and shock. and devastation that affected not just me, but everyone around me, know, all my loved ones. And it's horrendous. What psychological support is there for people who have this diagnosis?

There is both professional support and then there is peer support. think I would split it into those two things. Psychological support is not as easily and readily available as it should be for an awful lot of people, for the people that need it. And certainly when you get a diagnosis of metastatic breast cancer, then, you know, as you've said, the impact is huge. You know, I've said it rips your world apart. The world comes crashing down and that grief is real because you're thinking about the future and what you might lose out on, what you'd hoped for, what you dreamed for. you know, may not be there. And the biggest part of this is that uncertainty. You know, you can hopefully live and live well, but you're never knowing what's around that corner.

So I think getting some psychological support early can be helpful. However small that is, an impact, however often that is, maybe you don't need as much input as some people, but some people do need that healthcare professional type stance. So by that, I mean talking. therapies, some counselling, there's all sorts of things out there, ways to manage that anxiety. We're not going to fix it and take that anxiety out, but managing that anxiety is key as well in those early days. And for some people, you know, that actually just helps them ground themselves, develop ways of managing the grief, the uncertainty, the anxiety that they might be feeling. And everybody's story is absolutely different as to how they manage that.

So Yeah, seeking some professional help. I'm a real one for finding out what there is out there and putting it in your invisible toolbox or up your sleeve, just in case you do need it, even if you don't, think you do need it right now. You know, there are waiting lists, there are different ways to access things and they're all different. So you don't know whether you can refer yourself. need to get somebody to refer.

The other part of that, as I said, is peer support. And I really genuinely feel that's peer support. of any description for anybody in this world can be truly powerful. That somebody who gets it, somebody who absolutely understands because they're going through pretty much the same as you're going through. They know what thoughts go through your mind. They know why you react in the way you do particular things can be really, really helpful. And at the moment, you know, what we've got is group support at Breast Cancer Now to enable people to connect. and to share and to support each other. And I know that's quite an undertaking is going into a group, particularly when you hear things that you perhaps are you worried about hearing things. But we need to sort of be able to support people to go in there and hopefully develop services that will just be stepping stones for people to feel comfortable to engage with that peer support, which can be. honestly really helpful to an awful lot of people.

Yeah, absolutely. you know, you were talking about waiting lists. I find that often the NHS or your hospital will offer you a series of six sessions of counselling, for example, but you do often have to wait weeks or months for those. it's tends to be that at the point you're at your worst is when you can't access the help. And then by the time the help is offered to you, you're feeling a lot better. often tends to be the case with people. what I would say in that scenario, if you can't pay for private counselling is that there are all these services that you talk of to fill that gap.

And if you're not someone who feels that they can walk into a group full of other people and sit in a room and talk about your breast cancer or listen to other people in a similar situation, then there are also online videos you can watch. There loads of episodes of this podcast. We've actually just done with, we've just done an episode with Sir Chris Hoy, who talks about his metastatic prostate cancer, which was diagnosed de novo. And some of the things that he talks about and talks about feeling are so relatable. And for me, just listening to that and hearing a person who is in the same boat and has experienced some of the same things is just. It's horrible because you're listening to someone else who's having to go through the absolute worst thing, but it's also comforting cause you realize it's not just you. sometimes if you hear the things that you are experiencing and feeling reflected in someone else's words, it's just helpful. It's just comforting to know that someone else recognises and verbalises what you are feeling in that moment. and, And that's actually why I feel so connected to this podcast because when I got my metastatic diagnosis, that was before I was hosting this podcast. And I just went and listened through so many episodes and heard so many people talking about it. And some of those people were going through the worst, but some of them were a few years ahead. And, know, perhaps where I am now four years ahead and felt a lot more hopeful and coping better and doing exercise and all those things. Yeah, that was really helpful to me.

And that's a really good point, actually, you know, that sitting down in a group is not something that people necessarily would want to engage with. not even sure whether I would want to do that if I found myself in your position. However, podcasts and a conversational pod, what podcasts are that conversation can feel. rather more normal, know, that just having it on in the background whilst you're doing something, while you're doing your jobs at home or you are actually working at home, that type of thing. And that allows you to sort of pick up on that support. Here are the people say that pick up information, pick up tips, but it's just in the background as any other sort of podcast or radio might be. And I guess, you know, the other thing is when you talked about. Chris and talking to him is, know, I talked about healthcare professionals, I've talked about peer support, but also listening to other people's approaches. And that is that listening to other people and other people's approaches can be really helpful because you may not think along those terms, but actually think, oh, I never really thought about doing mindfulness or actually engaging in relaxation. or some meditation, that's just not me, but I could give it a try if it works for other people. I'll give it a try and you may not have even thought to do that. So I think everybody deserves a sort of a broader experience or knowledge or, know, yeah, having other people's ideas just to consider, but that's got to be in the right context. And whether that's a podcast or whether that's a group or whether that's online is, you know, every individual's choice.

Sometimes what helps me now is maintaining a balance between being in this world and obviously being involved with Breast Cancer Now, knowing lots of other people with secondary breast cancer, but also keeping my normal life where I don't talk about breast cancer. you know, hanging out with friends, going for dinner in nice restaurants and just being normal Laura as opposed to Laura with secondary breast cancer.

Yeah. So yes, it's a real balance, but it's so different for everyone. You know, in the immediate aftermath, shall we call it, of that news, of that sentence, yes, your breast cancer has spread, we can't cure your breast cancer, then the world comes crashing down. We've said that several times over, but things will start to settle a bit. That doesn't change necessarily the outlook. It might not change entirely the way you or quickly change the way that you think about things. But I suppose as you go on, then you learn new skills, you learn sort of the skills of resilience, maybe you learn what works, what doesn't, what helps, what doesn't, and things will change as they go on.

And we know that there is that sort of up and down motion of people, yes, progressing on treatment and starting with the treatment and then things settling down again. And it's a very different picture for an awful lot of people compared to 10, 20. 20 years ago. just thinking sort of ahead and just knowing what's out there can at least help you get in and picking, know, sort of dipping in and out of things that help you in the, from a future perspective.

Absolutely. Yeah. And when people are first diagnosed with metastatic cancer, the very common question either for yourself or for the people around you is how long have I got? What does this mean for? how long I'm going to live for. And it's very tempting to Google that. But statistics can be very statistically in the sense of, you know, what you see on the computer screen is not necessarily what your life is going to be. How, what's the best way to approach that?

That's a really tricky question. I guess that depends on what type of person you are, because people will ask that question. They will also avoid that question. They don't want to know that. So information about anything, whether it's prognosis, whether it's, you know, or outlook, as we quite often refer to it as how long will I live? You know, is something that is very, very personal and you know, whether you want that information or not. Although I would say it's worth knowing whether you're thinking about whether you want that information, because it's another one of those things. Once you've heard the opinion of the person that's giving you that, then you can't un-hear it again. But for some people, it is really helpful. It gives us some sort of context as what they think their team might be looking at from a treatment, the success of that treatment, so that they can actually put things in place and do the things that they want to do whilst they're well and able to achieve that.

Generally, you know, I think I've written down statistics haven't really changed, but that's not because they haven't changed. It's actually because we're not still not great at collecting that data. Specifically in the UK we're not, but actually there's an awful lot of other countries in the world that are not doing great at that as well. There have been inroads. into that more recently and I know colleagues at Breast Cancer Now have been meeting with people from Canada, from Australia to really strengthen this. And also there's the national audit of metastatic breast cancer going on at the moment that is looking at the collection or maybe not collection of data and trying to sort of really encourage that and helpfully in the cancer plan recently then that commitment to collect data on metastatic cancers of any description but starting with breast cancer. was there and we're really pleased to see that. So we really need to hold somebody account to account for that.

But I was reading some data from I think from the United States that say probably about a third of all comers, if you like, that have got a metastatic breast cancer or stage four as they tend to refer to it in the States. We'll live for about, we'll live for five years, which is a real difference compared to 10 years ago when I came into my role or even. 20 years plus when I first started getting interested in breast cancer nursing. So there are definitely inroads, even if it's not down in black and white. And we've talked about the fact that, know, anecdotally, we know people, some people are doing much better than others, but there's still a huge amount of work to be done. You know,

I've talked about the biology of the cancer denoting what treatment you will have and the same goes for prognosis. So we've made really good roads. for people who are hormone sensitive, oestrogen receptor sensitive, their metastatic breast cancer is that, or HER2 positive as well. But triple negative is still lagging a little bit behind in sort of the work that needs to do to be able to understand it better, the breadth of that and also what we can do and the treatments that scientists can develop to help that as well.

And I suppose the other thing with just Googling generally, is that whole, know, Dr. Google is not your friend unless you're shopping for something. Dr. Google in this sort of circumstance, can, can all quite often not be your friend. And the other thing I suppose to bring up when you mentioned about Googling it is AI these days. It's a really important thing that people don't take AI summaries for granted. Look at the sources where that's coming from. It will usually give you a link. But people are starting to use AI more and more with regards to getting answers for things, but it can be unreliable. So check out your sources. If you're not sure about it, take it to your team, ask them about it. They are very well versed at doing that from Google being invented or internet being invented and now to the AI summary. But we're moving into a very new sort of area of that AI coming into play, but it's still really important to talk to your treatment team and ask those questions. and not take it for granted. And that's whether that is about prognosis or whether that's questions about taking treatment or what you can and can't take alongside treatment. Involve your team. You are a team together.

Well, I would say, and this isn't a question for you because it's just a comment really, but one of the hardest things about having metastatic breast cancer is not being able to plan your life when you don't know how long you might have. So for example, if I knew I had 10 years to live, I would be able to plan my finances so that I could spend as much money as I, you know, would last me that amount of time because you want to do things and you want to experience things and you want to enjoy life. But if you, if there's a chance, you might still be here in 30 years time, then you don't want to have spent all your money in the first year. And I know so many people that is a really big problem for, because it's just such a hard illness to plan for. obviously. the longer you live, the better that is. But it's also really confusing and hard and scary.

Absolutely. And I think, know, as even though it is a positive thing, obviously, as you've just said, that people are living longer, or lot of people are living longer, that doesn't mean to say that needs go away. It means to say that actually there's a growing population of people that are living with metastatic breast cancer that still needs some continued support. If I go back sort of 10, well, probably 20 years, Certainly people didn't live as long and actually caseloads of treatment teams didn't sort of grow and grow and grow because unfortunately people were diagnosed, had some treatment and did die reasonably quickly. That has definitely changed. And I know that treatment teams and nurses out there who are supporting those with metastatic breast cancer, their caseloads are getting ever bigger rather than smaller or staying consistent.

We can't possibly cover all the different types of treatments. So let's just touch really briefly on a few of them. But essentially with metastatic breast cancer, we talk about first line of treatment, which is essentially the first lot of drugs that you go on. And it's assumed that those drugs will work for a period of time, but then they may stop working. And that's what we call progression. And that's when you will often have a second line of treatment or a third line of treatment.

Let's just... Talk first of all about some of the more common first line treatments for metastatic breast cancer. So for oestrogen positive breast cancer and HER2 negative breast cancer, what might be first lines of treatment?

So the first line treatment is in guidance is taking something called an aromatase inhibitor. So that's a hormonal treatment alongside another targeted treatment called a CDK4/6 inhibitor. They've all got really long, complicated names. But essentially, researchers told us that these two things work really well together and quite often prolong the use of the hormonal therapy, which we were using on its own before the CDK4/6 inhibitors came along. So CDK4/6 inhibitor drugs are palbociclib, ribociclib and abemaciclib.

The aromatase inhibitor drugs that a lot of people have really only work in postmenopausal women. So for women like yourself, Laura, who are young, then we have to make you temporarily or the long term postmenopausal in order for that aromatase inhibitor to work. And what it does is basically stop oestrogen being produced in your body. So you will have... a drug to give you, to switch off your ovaries, stop them working, producing oestrogen there and make you postmenopausal in order to be able to take the aromatase inhibitor and the CDK4/6 inhibitors.

And when I first started coming into this job, I don't think I knew about CDK4/6 inhibitors. They've definitely come into play in the last six, eight years. My memory is they're much newer.

They're much, much newer, but a really common place. And despite the fact that some people still are assuming that their first treatment, even with hormone sensitive breast cancer, metastatic breast cancer might be chemotherapy, they are absolutely the first thing to start with, with for most people.

And I'm actually going for my monthly Zoladex injection right after this recording, which is what you mentioned that shuts down the, shuts down the hormones in the body basically. And HER2 positive. breast cancer, metastatic breast cancer. What might be the first lines of treatment for that?

So first line treatment for most people will be a few cycles of chemotherapy. So docetaxel, paclitaxel, and then in combination with Herceptin, so trastuzumab or pertuzumab.

We're back to the long names

Doing very well on these long names.

Have a lot of practice. And so that's HER2 lots of HER2 directed therapy alongside that chemotherapy. And once the chemotherapy, the cycles of chemotherapy are finished, then people stay with the pertuzumab and the trastuzumab for as long as their disease is under control or their and that goes the same for any treatment really, as long as it's keeping the disease under control. and they're managing that sort of side effects there, they're managing and you know, they've got a good quality of life on that as well. yeah, that's automatic sort of first line for most people.

And what about triple negative breast cancer?

So triple negative breast cancer, historically really, we've only had chemotherapy there, but we've had a growth of drugs to be able to use. So Depending on the situation for those with triple negative breast cancer, then there is a test to do something that's called PD-L1, which allows us to be able to use, if people test sensitive to that, then there is a couple of drugs and there's also a slightly different test depending on the drugs. So you'll get tested to see if you've got PD-L1, if you're PD-L1 positive and immunotherapy can then be given alongside chemotherapy as well. Otherwise people are looking at sort of a chemotherapy treatment.

We have recently recorded an episode with Nikki Wheatley on metastatic triple negative breast cancer, where we go into a bit more detail about what that is, what it means. People with triple negative breast cancer are often told that their cancer is more aggressive, which can be a horrible word to hear, a very scary word. So we have got a dedicated episode to that for anyone with that diagnosis.

Let's talk about progression. What do we mean by disease progression in metastatic breast cancer?

So disease progression means when the metastatic breast cancer that you know exists enlarges, so it gets bigger. Or it might be that you find that you've got met secondaries elsewhere in the body, so it pops up somewhere new or what you know was there gets bigger. And that can happen because We know that treatments are given for as long as they work. But sometimes the cancer cells, as much as we don't really want to give them credit for being really clever, they are. And it's a little bit like Darwin's theory of evolution that they adjust and adapt to be able to exist. So they do that and they manage to work their way around the treatment and continue to start to use different means of being able to stay alive, to be able to grow and to replicate.

Most people with metastatic breast cancer will be having regular scans. So whether it's a three month scan, a six month scan, they might be having brain scans, they might be having full body scans. Some people have PET scans. Some people have CT scans. There's sometimes MRI scans, there's all sorts of different things. One of the things I hear most commonly is scanxiety, which is not when sometimes when you go for a scan, people say, Oh, good luck. But actually the day of the scan is fine. Apart from you've got to have a cannula and some injections and. and stuff. What is the not fine bit is the waiting for the results or the day that you go in for the results, particularly if you're worried about something. We call that scanxiety. What resources do we have to cope with that feeling of waiting for results and not knowing what you're going to hear?

I think, as we've touched on before, sometimes just talking it through can, you know, be helpful hearing that out loud and asking for support around that. not going to be able to take that anxiety away. You know you need or you want that scan to know what's going on, but you don't really want that scan or at least you don't want the results. You want to sort of get through it and get to those results. So I think it can be really helpful if you don't know, if you can work with your team, number one, you know when your scan is going to be hopefully, but just knowing dates can help people manage things a little bit better. If it's open-ended as well, ring you with and let you know when to come back. That must be incredibly tricky. I can't even begin to understand or know how that must be feeling, know, how much must feel when that is the scenario. So sort of having a plan, working with your treatment team. I think letting yourself be with that anxiety, as in recognising that it's never going to go away, but thinking about the things that can help. So that might be what works best in keeping your mind occupied, what you need to do between, you know, the date of the scan and the results. talking it through with people, quite often people come to our groups or they ring the helpline, just they haven't got a question, they just are waiting and they just want to voice what it is that's going on through their head and how difficult that is. So I think it is drawing in the support, recognising that you can't change things, but wondering how, you know, what's going to help you manage that anxiety. And there's so many different things, whether that is a professional input again, or we're going back to that peer support.

You mentioned being busy there and I think that is the one thing that helps me the most with scans. IOT is just being really, really busy for the couple of weeks. Usually for me, it's a couple of weeks wait in between the scan and the results appointment. And if I'm really busy either with work or family life or whatever is going on during that period, then that stops me from worrying too much about it or just reading a really gripping. thriller or something like that, know, something really absorbing, I think is a technique that you can use.

I mean, I think, you know, lot of therapists will still sort of, prescribe that distraction technique is that's exactly what it is. It's not saying that the issue is going away. The issue is not going to go away, but you just need that distraction or at least you, you know, if you find it's overwhelming is letting yourself have time to think and to worry about it, trying to brush it under the carpet doesn't, doesn't work necessarily. It's going to manifest itself in some way. So allowing a bit of time to do that, but also then sort of committing to getting on and doing other things that distract you works for a lot of people. But yes, you're right. Acknowledging that you are worried and you are allowed to be worried.

Absolutely. If you've got this diagnosis, you're absolutely allowed to worry that it might worsen and it might not, but you're allowed to worry about that.

What about clinical trials? We hear a lot about clinical trials, but it's a bit of a mystery area. And I think sometimes we think, okay, there's no more treatments being offered, but there might be the option for a clinical trial. But actually you can. have a clinical trial before all your treatment options have been exhausted?

Absolutely, yeah. So clinical trials are quite a key part for an awful lot of people that have got metastatic breast cancer, key part of their treatment. And as you've just said, no longer are they a last option. They can be sort of brought in at any time. Obviously, if you're on treatment and it's working, nobody's going to stop treatment in order to go on to a clinical trial.

I think it's something that people need to know more about. I think they need to know about it before they're ever asked about a clinical trial. Or maybe they're thinking, well, if I want to know about whether I would or I wouldn't, if it came to it, if my next, you this treatment that I'm on stops working, I'd quite like to ask about clinical trials. So I want to know the basics about clinical trials, first of all, to know what is, you know, so the things that come up quite often is, well, I'm really scared of getting a placebo and a placebo is, you know, a sugar tablet or something that is not going to do any good. That will never happen for somebody who's on a clinical trial and when they've got metastatic breast cancer, you will always get the standard, the current standard of treatment, whatever that is. And then that will be sort of measured against, you know, a newer drug or a drug that's being used slightly differently in a different combination, that type of thing. So you're not going to lose out.

I guess for some people, the worry is that they might not get the newer drug that they think might be helpful, but we never know whether that's going to help. So there are a lot of pros and cons. probably too many for me to list here. And actually, I don't feel like a specialist in that. What I do know is, it's everybody's right to know about clinical trials, make seconds count, have their clinical trial service, and do an incredible job at giving that information about clinical trials and also helping people find a clinical trial if they can give some information about their situation to see what might be possible. A lot of people empower themselves by referring themselves to Mel Tolson and her team. The service makes seconds count.

Some people are being treated in centres who are very proactive in recruiting people to clinical trials. And when I mean that, I just mean offering that opportunity. People need that information to make that informed choice. And you need to go away and study information. they have to give you so long to be able to look at that. to whether you want to join a particular trial. But some people find that their oncologists don't offer trials and yet they're still interested. So the Make Seconds Count service definitely brings that to life and offers that opportunity. my one tip would be just to explore that, not with any obligation, not with any expectation, but just to explore that. And certainly people are on trial second, third line these days, quite early on in their treatment.

Yeah. So Make Seconds Count is another charity, brilliant charity for metastatic cancer. we've had them on this podcast, Claire from make seconds count a couple of years ago, and she talks in detail about applying, getting involved in that clinical trials sort of pathway. So I, for example, at this stage, when I'm still on a treatment that's working, I can go on their website and just get into this system, which means that if at some point I need the clinical trial, they. will already have talked to me about it and considered me for it.

Absolutely. It's going back to what I said about having something up your sleeve or in that toolbox thinking, OK, I've had the information. I think that's something I would want to do. Or no, having heard that information, a clinical trial is not something I would want to do. I'd just stick with the standard treatment that I'm offered and have those discussions when they come up. But it is allowing people to make their own choice about that. And it's important to get it in early, I think, rather than at the time of... need, like you said.

Let's talk about one of the more difficult stages of metastatic breast cancer, which is when you've had first, second, maybe third, however many lines of treatment there are, and they've all stopped working and you've been told by your treatment team that there are no further options available to you. What happens then?

Okay. So you've just described a set of people who've come to the end of sort of treatment options that are available to them and that we know can help, that we can work. I suppose the other thing to say at this point is there will be people that might make that decision even if there are some other treatment options available to them that actually they've had enough of the side effects of the way that treatment and the cancer makes them feel and they make that decision. which is incredibly difficult for both them and can be difficult for families as well when the expectation is that they carry on with that.

I suppose what this brings up is the importance of what we still call the palliative and supportive care service. Enhanced supportive care clinics are starting to... happen in a lot of hospitals which help people live and live well with their cancer. So the automatic assumption for still for a lot of people is that palliative and supportive care is only for end of life or is only for those people that have come to the end of their treatment options. And actually, although that's not specific to your question, it can be really helpful upfront to go in parallel with the medical treatment and the conventional treatment that you're having. Palliative and supportive care treatment can help. people live and live well, it's exactly what they're there for.

But the other part of their care and their input is for those with end of life or at least when they've come to the end of their treatment options or chosen to do that. So you would have hopefully an established link maybe with a palliative and supportive care service. Palliative and supportive care services run out of hospices, they run in the community, they might be in the hospital. And I always feel that an establishment of that relationship as early on as possible. is really helpful so that you don't get to that point where you need them and you're in not crisis but end of life and you need an awful lot of input and that's not from strangers. So again, finding out where that input could come from, seeing whether you can be referred is really helpful upfront.

But essentially what we're talking about is what people often refer to as best supportive care. And that means you're not having medicines to... Treat your cancer, but you are having medicines and treatment and support. and care to be able to help you manage the side effects of your cancer. So that might be breathlessness, it might be nausea, for a lot of people it is pain, sorts of things. And there is evidence in actual fact that when people have had palliative and supportive care alongside, this was done with lung cancer patients, that they actually live that bit longer as well, live well and live longer as well. whilst I'm not an expert in that, and we've got great charities like Marie Curie who've got a helpline loads of resources on there, then their input can be invaluable and not least because of those side effects that we're talking about, the symptoms, but also just the other support for families, for children, all sorts of benefits, finances, all sorts of things palliative and supportive care teams can offer. I'd see it as sort of slipping in alongside the treatment, but certainly, you know, they come into play with their care, their treatment and their expertise once people have made a decision or have come to the end of their treatment options.

You mentioned briefly benefits there. What financial support is there for people with metastatic breast cancer?

There are an awful lot of benefits and financial sort of advisors out there. I know Macmillan have the opportunity for you to meet a financial adviser or maybe speak to them on the phone. A lot of them are based in the cancer information centres. You can ring them on their helpline to find out the best way of accessing them. Citizens Advice, have them that sort of thing. people will be assessed and obviously fill in some forms to be able to apply for what's called PIP, so the Personal Independence Payment. For people with metastatic breast cancer, quite often there is the ability to be able to fill in a form that brings them under what I'm going to term the special rules. We talk about special rules, which means that they are able to claim quite quickly and quite an enhanced sort of rate of that payment as well. That form does these days sort of say to the person that's filling that form in that they don't. or they wouldn't be surprised, I think is the terminology, that this person might die within 12 months. So that is really quite a tricky thing to sort of negotiate and a tricky thing for you to hear. But actually what that does is help a lot of people access those benefits and that financial advice.

Financial advice goes beyond benefits. know, there may well be people that will ask you about your financial affairs, help you set up trust funds, help you access your insurance, critical care. All those sorts of critical care cover, all those sorts of things as well. So asking for specialist advice on that is something that we would always direct people to Citizens Advice or Macmillan because you want somebody that knows their stuff about that, but it's there. would also say that the charity Maggie's is also brilliant for that. They have cancer centres near some of the hospitals around the UK and they're absolutely brilliant. You could just walk in there and say, can I talk to you about this or that? financial stuff or whether you just want to access a box of tissues and have a good little cry with a free cup of tea or coffee and a biscuit, they're great.

For listeners looking for support of any kind, whether it's someone who's worried about signs or symptoms of metastatic breast cancer or someone who's had a recent diagnosis, how can they contact Breast Cancer Now as nurses and speak to the lovely people like you?

Okay, so our helpline, staffed by nurses. You can ring us on 0808 800 6000. We are open Monday to Friday, 9 till 4 and on a Saturday, 9 till 1. We're not open on a Sunday. We do have English bank holidays off, but you can always ring us and leave a voicemail if we are busy and you can ring and leave us a voicemail even out of hours. So if you're awake during the night, even though we're not accessible and you think I want to speak to a nurse, first thing tomorrow morning I would like them to try and ring me back, then you can leave us a voicemail. That's not a problem.

Some people want to write to us. So we've got our Ask Our Nurses written inquiry service. So that's available on the website or our email is nurse@breastcancernow.org. Or you can ask us a question on our forums. So you would use the website if you want to get a private response. So that will be a private submission and a private response. On the forums, other people can see your question and also see the answer, which actually for an awful lot of other people is really helpful because they might be thinking of the same question as you as well. And loads of people contact us via social media, privately or on public posts. So loads and loads of opportunities to get in contact with us.

And there's no question too silly or too obvious really that people can call up with anything, whether it's emotional support or they're concerned about a sign or symptom.

Absolutely. Yeah, no question is too silly, too simple. And as soon as you start opening the door and answer one question, then you suddenly realise that you've got other questions. You've got the nurse on the other end of the line. And for us working at Breast Cancer Now on the helpline, it's a real pleasure to have the time, you know, rather than working in the NHS where time is really precious to everybody. Then it's a real luxury to have the time to be able to take with people.

And you're right, you don't even need a question. You might ring up and just say. I don't really know why I'm ringing today. I just needed somebody to be there to be with me today and just to listen to what's going through my mind. That's equally okay.

And you should, if you are diagnosed with metastatic breast cancer, you should also be assigned a clinical nurse specialist or CNS at your own hospital. So you should also have that, that person that you can speak to. And if you don't, you can call breast cancer.

Absolutely, yeah. We know that metastatic breast cancer, CNSs, clinical nurse specialists are not absolutely everywhere in the country. Since I came into this role, certainly there's been a lot more that are in role that those roles have been approved by their trust and brought into use. And I know so many people that we speak to on the helpline find it really helpful to have that person there. Equally, people are frustrated that they don't have access to that person. But a clinical nurse specialist of some kind can be really helpful and a real sort of good connection to other services and support as well. So if you don't have a clinical nurse specialist, ask for one.

Yes. We've covered quite a few of the different areas of metastatic breast cancer, quite a broad area, but there are so many other things we haven't had time to talk about. One of them is grief and parenting and talking to children when you've had a metastatic breast cancer diagnosis. Fortunately, we have a separate episode with Caroline Leek from Fruitfly Collective where we talk about parenting of children. But we have a separate episode where we talk about grief and dying and talking about death with children in a really, really approachable way. So I would point people towards that episode. as I've mentioned here, we've got so many other episodes where we've spoken to people like Laura Middleton-Hughes and Nikki Wheatley about different areas of metastatic breast cancer. So there's loads. and loads of resources and support on this podcast. So I hope that people will feel sort of heard and seen and supported through this podcast as well.

If our listeners were to take away one thing from this podcast episode, what would you like them to know?

I just want them to know that Breast Cancer Now is here for them. And whether you're listening, cause you've got metastatic breast cancer, whether you're listening cause you've got primary breast cancer. or whether it is that you're supporting somebody that's got either of those diagnoses, then the starting point for me as a nurse would always be the helpline. Speak to one of us. We'll signpost you to the services that we've got for the support, but we equally have a huge sort of directory in our minds of other things that are out there.

And I really want people to know that we're here. So even if you're listening and you haven't got breast cancer, but you know somebody that has or somebody in the future, you come across somebody. please tell them that we're here. We constantly and still here.

I wish I'd known that you were there before. So please let's make sure that everybody knows that we're here and we can do the signposting and the supporting.

Amazing. Thank you so, so much. Not only for everything that you've shared with us today and all the support you've given, but all the support that all the nurses, all the nurses out there who are listening and who are not listening, bring to all of us, metastatic and non-metastatic breast cancer patients because without the nurses we would be nowhere and that's making me emotional just saying it because I'm so grateful and I know so many other patients who are really, really grateful. So thank you, Catherine, for coming on the podcast and thank you for all your hard work.

Thank you. I will definitely take that back and equally it's just as nice and just as emotional to hear that from the other side of nurses. Everybody is working so hard, so flat out and just to have that one little bit of... you know, sort of positiveness and that thank you will mean a lot to an awful lot of nurses. So thank you, Laura.

Thank you. We do appreciate it.

Thank you, Catherine.

Thank you.

If you enjoyed this episode of the Breast Cancer Now podcast, make sure to subscribe on Apple Podcasts, Spotify or wherever you get your podcasts. Please also leave us a rating or review on Apple podcasts and perhaps recommend it to someone you think would find it helpful. The more people we can reach, the more we can get Breast Cancer Now's vital resources to those who need them. You can find support and information on our website, breastcancernow.org, and you can follow Breast Cancer Now on social media @BreastCancerNow. All the links mentioned in this episode are listed in the show notes in your podcast app. Thank you for listening to the Breast Cancer Now podcast.