64 In examining different coping strategies, studies indicate that patients’ attempts to cope by avoidance turn out to be far more distressing than direct and active discussion and problem solving, a finding in many serious diseases[47] . Numerous studies have found that better emotional functioning is strongly linked with fewer physical symptoms[48-52] . These multiple symptoms interact with one another in unknown ways. As one notable example, 56 consecutive newly diagnosed MBC patients in one hospital-based study[51] , when scored for health-related quality of life and coping capacity using a series of validated measures, reported “multiple, concurrent and interrelated” symptoms, with two thirds reporting 10 to 23 symptoms. In another study, clusters of symptoms tended to be associated with one another: for example, fatigue, drowsiness, nausea, decreased appetite, and breathlessness[53] . Adjustment to illness, write Brennan et al.[54] , involves “ongoing psychological processes that occur over time as the individual, and the individuals in their social world, manage, learn from, and adapt to the multitude of changes which have been precipitated by the illness and its treatment.” Fortunately, many patients and families become quite knowledgeable about MBC and how to live with the disease. Time passing since recurrence or diagnosis can moderate psychosocial distress[55] . Coping and adjustment are extremely complex processes, however, and not all MBC patients are equally resilient. Longer-term adaptation after MBC diagnosis has not been widely studied. However, in 1 survey, nearly half of patients with HER2+ breast cancer surviving more than 6 years after MBC diagnosis still reported symptoms of anxiety and depression, despite decreased physical symptoms[56] . In surveys, most patients’ overall satisfaction with their HCPs is good, and they generally believe they are coping well despite the challenges they face[57, 58, 60] . They attribute the coping to their own resilience and spiritual beliefs and to the kindness and generosity of others[61] . A number of small qualitative studies across diverse socioeconomic and racial populations of women with MBC have reported that maintaining hope is a critical factor in coping[62] . Psychiatrist David Kissane describes the challenge of living with MBC as a confrontation of existential suffering[63] . Feelings of hopelessness and futility, loss of faith and transcendence, loneliness, shame, fear of dependency, profound sadness, and death anxiety are all part of a universal and fundamentally human struggle as patients deal with their mortality. Each challenge contains within it the seeds of transformation and adaptive adjustment. And “physicians can do much,” says Kissane, “to nurture courage and maintain each person’s sense of meaning, value, and purpose.” In conclusion, interventions for anxiety and depression in MBC patients represent a crucial service that health care workers can add to the patients’ and families’ own set of coping tools. Appropriate referrals to mental health professionals, for medical and nonmedical treatment and other interventions, are important, whether the referral is for pharmacological, behavioral, or psychological intervention or some combination thereof. An extensive literature exists on the efficacy of various methods of helping cancer patients confront psychosocial issues, symptoms of disease, and side effects of treatment. Sources of emotional support, individual and group psychotherapy and counseling, as well as adequate information about the disease, its treatments, and methods to alleviate symptoms and side effects have all been shown to be useful in helping patients to cope with and adapt to their disease[64] . Accesstomental healthservicesisoften eitherlackingorisnot pursuedbypatients whocouldbenefit. Emotional distress tends to worsen with disease progression, as symptoms and side effects increase.