Coping with the symptoms

Metastatic breast cancer and the related treatments can lead to fatigue. Some women are hardly affected by this overwhelming exhaustion and tiredness. But others may have very severe or persistent fatigue, or it might come back again and again.

Severe fatigue can significantly affect your everyday activities and quality of life. It can be accompanied by problems with sleeping, concentrating, and remembering things, as well as feeling down. It is not known what exactly causes fatigue. A great deal of physical and emotional stress is assumed to be responsible. For instance, the disease and treatments can lead to weight loss and weakness.

Unlike normal tiredness, fatigue is hardly improved by rest and sleep. Although it might sound contradictory, certain types of physical activity actually tend to reduce fatigue. Things like going on regular walks or doing light exercises may be suitable. It is sometimes possible to do strengthening or aerobic exercises too. The following approaches might also help to cope with fatigue:

• Planning your day: Watch how your energy levels change over the course of the day and plan activities and breaks accordingly.
• Setting priorities: Delay things that are less urgent and let other people take care of less important tasks.
• Doing one thing after the other: Break up activities into small steps, only concentrate on one task at a time.
• Organizing practical help: For instance, get support in everyday life from a domestic helper.
• Distracting yourself: Do things you enjoy, like listening to music, reading or watching television.
• Don't sleep too much during the day: Only take very short naps, if you have to – otherwise it might be harder to sleep at night.

Regular exercise can help some women to keep up or improve their physical fitness. An individualized exercise program is one way to reduce exhaustion, improve sleep, lighten your mood and see your body in a more positive way again. Special exercises led by a physiotherapist can help increase flexibility and strengthen your muscles after surgery. Exercise also seems to relieve lymphedema-related problems.

If your cancer is at an advanced stage, it's important to talk with your treatment team about what physical activities are possible and suitable. These may include things like going on regular walks, swimming, hiking, dancing, mobility exercises or specific strengthening exercises. It is important that you enjoy the exercise and feel good during it, and that you don't overdo it.

You can also participate in special sports activities offered as part of cancer follow-up care. In Germany, activities that are prescribed by a doctor are covered by statutory health insurers. Organizations like cancer information services and local support groups can help you to find out what sports courses are offered in your area.

Some women find it hard to do exercise. Or they find it depressing if they don’t see any progress. If you feel that way too, one option is to take a break for a while. You might feel more like doing exercise after some time, and then start up again. The important thing is to make sure that what you do feels good.

Many people think that certain diets can prevent cancer or help you recover. But research on the influence of diet in breast cancer hasn't found any direct effects on the risk of developing cancer or on how the disease progresses. In other words, there are no foods or diets that can cure the cancer or slow down its progression.

There's usually no need to take dietary supplements. You can normally get all the nutrients that your body needs by eating a normal diet. The recommended amount of calories for people who have cancer is generally no different from the amount that healthy people need.

In advanced cancer, though, it can be difficult to regularly eat and drink enough. The disease and treatments can sometimes reduce your appetite and thirst, and your sense of taste might change.

It is important to eat what you feel like eating and enjoy. If you sometimes find it hard to eat anything at all, you can try the following:

• Drink a lot of water, as well as things like milk, tea, warm broth, vegetable juices or fruit juices. It can be helpful to make yourself a big pot or jug of the drink and aim to finish at least a whole one per day.
• Instead of having three main meals a day, eat several smaller meals.
• Eat easily digestible foods such as white bread, clear broth and yogurt – even if you're feeling nauseous (sick).
• Replace solid foods with liquid foods, blended foods or easy-to-chew foods (such as smoothies, oatmeal drinks, semolina pudding, mashed potatoes, scrambled eggs and creamy desserts).
• Prepare small snacks that you can eat as soon as you start feeling hungry (like nuts, granola bars, dry fruits or cheese cubes).

If you're unable to eat solid food for several days, you should talk to your doctor.

People who have advanced cancer often have constipation. This may be caused by side effects of medication, getting too little movement, eating a low-fiber diet or not drinking enough fluids.

Not having a bowel movement every day generally isn't a problem in itself. It becomes more of an issue if you develop things like abdominal pain or the feeling that you can't empty your bowels properly – or only if you strain a lot.

If you're suffering from constipation, you could try to drink a lot of fluids and, if possible, eat more high-fiber foods, such as

• whole grain products,
• vegetables,
• fruits and
• nuts or seeds.

It is best to talk to your doctor about whether treatment with laxatives is an option.

If you experience discomfort, put on a lot of weight or lose weight without trying to, professional dietary advice could help you to find the right kind of food. In Germany, dietary advice and support is often offered by cancer centers (Krebszentren), rehabilitation facilities, some hospitals, statutory health insurers and nutritional advice centers (Ernährungsberatungstellen).

Keeping a food and drink diary can help you to keep track of exactly what – and how much – you actually eat or drink. To find out how much energy you use up, you can also use the diary to make a note of how much movement you get and whether, for instance, you go on a walk or do exercises. Problems like nausea or constipation can be noted in the diary, too. It can also be helpful to take your food and drink diary along when you go to doctor's appointments or dietary advice appointments.

Many women feel less sexual desire as a result of the cancer and the treatments they have. Sexual needs often become a lower priority due to things like the pain and physical limitations, tiredness and exhaustion, a new body image, and emotional distress. What's more, the treatment affects key aspects of femininity: One breast may have been removed or it might now have scars on it. Hormone therapy or chemotherapy may lead to loss of fertility and hormonal changes before menopause.

Some women also withdraw sexually because they worry that they're no longer attractive enough. But the fear of being rejected for physical reasons is usually unfounded.

Over time, it's often possible to accept the changes caused by the disease and to rediscover any sexual desire that might have been lost. A satisfying sex life is good for the body and soul. There’s more to sex than sexual intercourse, which might not always be possible, or less pleasurable at times. Also, sexual preferences and habits differ from couple to couple, and can change over time even without an illness being involved. For instance, sexuality can become gentler with age, and you may need more time to get in the mood.

Possible ways to improve your body image and stimulate your senses include pleasurable body care or beauty treatments, as well as exercise – be it walking, yoga, dancing or pelvic floor exercises. Pampering each other with massages is relaxing and can help you feel closer (again).

Some problems have simple, practical solutions. For example, if your range of movement is limited, cushions can give support. Lubricants can help with vaginal dryness, which is sometimes a side effect of hormone therapy.

It is not always easy to change habits and find new ways of doing things. It may help to take your time and talk openly with each other about your needs, fears and feelings.

Even if you don't have the energy or feel any desire for sexuality, physical contact and tenderness are usually still important and pleasant. These things can help couples to feel intimate and close. It is easier if the partner understands the changes the woman has gone through and is sensitive to them.

A partner might also lose the desire for sex – perhaps because they may also feel burdened by the cancer, the new situation or concerns about their partner. Some might be afraid that their own sexual needs could put too much additional strain on their partner.

It doesn't necessarily have to be a problem if sexuality ends up not playing a major role in your relationship for some time. As long as you feel close as a couple and accept that the breast cancer has changed this aspect of your relationship too, there's no reason to worry. But if you feel that the lack of desire is affecting your relationship, it might help to talk openly about your feelings and worries with your partner.

It isn't always easy to talk about sexuality, and may take a little courage. Sexual health centers, cancer information centers and psychosocial counseling centers offer help here. If you like, you can get advice from them anonymously too. Support groups give you the opportunity to talk to women who are in a similar situation to you. They can also put you in touch with other women who have advanced breast cancer. Some support groups provide online forums too, where you can chat anonymously and informally with others affected by the disease.