You are required to critically discuss the experience and impact of an aspect of metastatic breast cancer on patients and make recommendations for service or role development.” • Identification of an aspect of metastatic breast cancer which impacts on patients and/or their families, linked to the student role and local service. • Critical exploration of the opportunities for service development to improve the patient experience with the discussion of the implications for own professional practice.

There has been real developments in HR+ HER2- treatments options over the last couple of decades with third generation’s aromatase inhibitors such as Letrozole and Exemestane becoming the standard hormonal treatment for pre and post-menopausal woman. Zanotti et al (2017) as well as the newer targeted therapies such as palbociclib and ribociclib used alongside an aromatase inhibitors. (AIs) The cyclin-dependent kinases 4 and 6 (CDK4/6) inhibitors have shown in clinical trials that they are able to slow down or reverse resistance to endocrine therapy thus increasing the median that patients may stay on an AI such as Letrozole then just on monotherapy endocrine therapy. (Boér 2016).

Gluck (2014) suggests that MBC patients that are HR+ and Her2- the first line gold standard treatment would be to consider endocrine therapy unless in visceral crisis or are symptomatic. Therefore for patients with HR+ MBC, endocrine therapy is the preferred initial treatment. Although Endocrine therapies such as Tamoxifen and Letrozole are not without their own adverse effects.

This essay will look at the impact on these endocrine therapies induced effects specifically the menopausal symptoms and their impact on the patient QOL, how these symptoms can be manged in order for compliance in treatment and to manage the longevity in treatment thus keeping the line of Endocrine therapy options open. (H Seker et al 2013.)

The profound psychological effect on diagnosis of MBC and endocrine therapy can be compound by the onset of the menopausal symptoms and its effect on the vulnerability of the MBC patient Johnston (2010). The complexity of the management of these symptoms with Hormone replacement therapy are often seen as contra- indicated (Eden 2016) However Seker et al (2013) who compiled an retrospective study into the use of hormone therapy and alternatives suggest that there may be more research needed in the management of hormone therapy in oestrogen receptor positive cancer but it must be noted that this research was a retrospective study on all oestrogen receptors dependent cancers types and endocrine adjuvant treatments. In view of this it remains controversial to prescribe hormone replacement therapy to HR+ breast cancer.

To concur hormone replacement therapy is seen as the most effective treatment for menopausal symptoms but as mention prior and with accordance to nice guidelines (2009) there are contra indications for HR+ breast cancer patients. (Eden 2016.)

Therefore, what are the implications to professional practice and the service provided, often the MBC patient who experience early menopause through chemotherapy, oophorectomy or anti-oestrogen treatments develop problematic symptoms such hot flushes, night sweats, sleep disturbance. Depression, joint pains, vaginal symptoms which can greatly impact on the patient QOL. Compared to those that have a more natural menopausal transitions the impact of these symptoms are often increased in severity this is possibly due to the patient being forced into a much quicker menopause either surgical or medically Hickey et al (2017). The severity of these symptoms can greatly reduce the patient tolerance to Endocrine therapy, often leading to patients stopping treatment or switching to another endocrine therapy therefore limiting treatment options before it is necessarily required. Thus the implications to my role is to help manage these symptoms and improve tolerance to the endocrine therapy with improving the overall QOL. This will be discussed using evidence based knowledge in non-hormonal management of menopausal symptoms.

How as a service we can support the patient through symptom management clinics in order to maintain a QOL and tolerance to the treatment.

Henke Yarbo et al (2013), the menopause is the cessation of menses, this could happen naturally within part of a female natural life cycle or as a result of medical interventions such as chemical, surgical or radiotherapy. A natural menopause can happen over period of time the symptoms experience are individualise to a healthy women if not somewhat troublesome to that woman. However, women with a diagnosis of cancer could find the management of menopausal symptoms burdensome with a limited treatment options such as HRT. The MBC patient is not only dealing with a diagnosis of incurable cancer they are having to manage the side effects of treatment induced menopause alongside the direct conflict in the management of their disease with the implications that the menopause can have on their QOL. (Eden 2016).

There are a number of symptoms which are associated with the menopause therefore the focus will be on the most commonly reported and burdensome symptoms to the postmenopausal patient, such as hot flushes, night sweats, sleep disturbance, depression as well vaginal atrophy joint pain. For the purpose of this essay hot flushes sleep dis