72 6. Practical Issues: Work, Insurance, Finances The practical issues MBC patients and their families face are monumental. Surveys reveal that financial hardship is a fact of life for many families, driven by inability to work, for both patient and family caregiver; travel expenses; and high out-of-pocket co-payment and treatment costs[58, 59, 61] . Merely having health insurance may fail to insulate patients from the financial impact of expensive and ongoing treatments[91] . In patients with early stage breast cancer, compliance with treatment decreases as the amount of co-payment increases, suggesting that patients may be forced to choose between treatment and other expenses[92] . As the cost of new treatments escalates to levels far exceeding the annual income of most families, it’s easy to imagine patients having to make difficult choices, especially during the 2-year lapse between Social Security Disability determination and Medicare coverage, when many families’ savings are depleted[93] . High rates of bankruptcy have been documented, particularly among MBC patients under 65 years of age, in a population-based study[94] . The majority of MBC patients are in the workforce at the time of diagnosis. Within the first year of treatment, at least half have quit or lost their jobs, which often results in greater financial problems and a lower standard of living than before diagnosis[57, 61, 95] . Most patients report being unaware of available resources that help address financial need. For example, one quarter of the MBC patients completing an online survey in the US were not aware that MBC patients with a certain amount of work history qualify for Social Security Disability benefits. Although few of the more advantaged patients who completed the surveys had to forgo treatment because of financial circumstances, many missed vacations, celebrations, and social events and depleted their savings[58, 95] . Other practical needs that MBC patients report as problematic include accessing transportation to health care facilities; managing the home, child care, and shopping; getting help with applications for disability or insurance benefits; obtaining medical referrals; and finding help with work-related issues, such as Americans with Disabilities Act protections and medical leave[3] . The practical issues MBC patients and their families face are monumental. Despite the challenges they face, most people with MBC and their families demonstrate considerable resilience, adaptation, and courage as they continue to live with the disease.