65 2. Emotional Support For MBC patients, emotional support from family, friends, community, other people living with MBC, and HCPs plays a crucial role in decreasing psychosocial distress. Research across many diseases indicates that emotional support is strongly associated with improving health outcomes and even extending life. Between married and single patients with MBC who feel hopeless, the single patients are more vulnerable to depression[65] . In surveys, MBC patients generally report receiving adequate emotional support from friends, family, community sources, and HCPs. However, survey respondents are more likely than other MBC patients to be partnered and have sufficient financial and social resources, and they may therefore be less isolated overall. Chronic, debilitating illness such as MBC often leads to increasing social withdrawal[66] . Sometimes described as “a marathon, not a sprint,” life with MBC involves challenges that last for months and years, not days and weeks. Over time, sources of support can erode. Friends and family may not comprehend the toll that continuous treatment takes or the inevitability of disease progression. Even patients who feel well supported initially or in times of medical crisis may find that support from friends, family, and community tends to wane with time and as the disease progresses[57, 61] . Nearly half of surveyed MBC patients report a sense of stigma, of feeling like outcasts or feeling isolated, especially within the larger social context of the breast cancer community. Symbolized by ubiquitous pink ribbons, support for patients with early breast cancer is highly visible and widespread[58-60] . MBC patients can feel silenced by the “triumphant, happy and healthy” rhetoric of breast cancer organizations[67] . Access to online peer support is important to many MBC patients who are Internet users. Surveys and studies have reported great benefit from contact with other MBC patients[3, 58, 59] . Most MBC patients say they highly value information and support from patients like themselves and that it helps them to cope and to feel less alone. However, few of these patients’ HCPs recommend support groups or other contact with peers[57] . A cost of spending time with other MBC patients is the inevitable disease progression, which may be perceived as “too depressing” and may heighten emotional distress to the point where the sense of camaraderieandsupportisoutweighedbygriefand fear[68, 69] . Studies ofhospital-basedgroups donot tendtobenearlyaspositiveregardingpeersupportas arestudies ofonlinesupportgroups[70, 71] . Emotional support is strongly associated with improving health outcomes and even extending life.