**10. Palliative care for bladder cancer patients**

Bladder cancer is the ninth most common malignancy in the world [147]. The 5-year survival for bladder cancer is 76.9%, however, metastatic disease 5-year survival rate is only 5.5% [148]. It is mainly seen in elderly people [149]. Bladder cancer can cause persistent and disabling pain in patients [150] pelvic pain is one of the major end-of-life complications in people suffering from bladder cancer [151]. The pain control in some cases was adequate with fentanyl patches [152] bleeding can also arise from the bladder cancer, or as a result of radiation or cyclophosphamide, infection can also worsen bleeding. Patients with severe haematuria can be treated with palliative TURBT, tranexamic acid, palliative radiotherapy, embolisation, palliative chemotherapy, and urinary diversion [153].

## **11. Palliative care for breast cancer patients**

Breast cancer is the most common cancer among women worldwide and the most common cause of cancer death in women. About 23% of the 1.1 million female with cancers newly diagnosed every year. And about one-fifth will survive for 5 years; American Cancer Society estimated that breast cancer is the second only to lung cancer as a cause of cancer death in women [154–159].

#### **11.1 Pain**

In general, the major causes of cancer-related pain in breast cancer women are bone metastases [160, 161]. Opioid analgesic medications can be submitted for

patients with strong pain, in the case of neuropathic patient, patients may get benefit by combined analgesic with an agent with special efficacy for this mechanism of pain like tricyclic, SNRI, and/or an anticonvulsant. Radiotherapy may be also important in case of bone metastases for patients with poorly controlled pain [161–163].

#### **11.2 Breathlessness (dyspnea)**

Patients with breast cancer usually suffer from breathlessness; there are many causes of dyspnea and for its management, non-pharmacological and pharmacological approaches can be used [39]. Sitting the patient in upright position, use of bedside relaxation techniques, and accelerating air flow over the face using a fan or open window, are all helpful. Also, large symptomatic pericardial or pleural effusions should be drained. Oxygen supplementation can decrease dyspnea for patients with hypoxemia. Opioids are also approved for symptomatic therapy for dyspnea at the end stage of the disease [164].

#### **11.3 Fatigue**

Fatigue is the most common cause of distress to the patients. Restoration of energy strategies involved taking adequate nutrition and rest, decreasing stress can be done by several techniques like meditation or relaxation. Physical exercise proved to be useful in many clinical trials [165]. Fatigue patient's anemia with a hemoglobin of lower than 8 g/dL may require blood transfusion to maintain a hemoglobin level between 10 and 12 g/dL. Some studies mentioned that methylphenidate or modafanil can be useful for patient with fatigue symptoms but till now there are some limited data about its benefits regarding fatigue [166]. Steroids may have a role in short-term control or decease of fatigue for a patient who needs to be in his optimal alertness for an important family event or special occasion, but there is no benefit in long-term fatigue management [164].

#### **11.4 Depression**

Patient having cancer can be depressed experience, its incidence lower than anxiety. Although, it can be underreported by patients [167, 168]. Depression in cancer patients usually needs combining antidepressant medications, supportive psychotherapy, and cognitive-behavioral techniques [169]. Antidepressant is the main management for cancer patients with severe depressive symptoms that should be accompanied by psychotherapy by a professional therapist. That include selective serotonin re-uptake inhibitors (e.g., fluoxetine, sertraline, paroxetine, citalopram, and fluvoxamine), serotonin-norepinephrine reuptake inhibitor (e.g., venlaflaxine), and the serotonin-2 antagonists'/serotonin reuptake inhibitors, nefazodone and trazodone, and psychostimulants (e.g., methylphenidate) [170].

However, home palliative care enhances care and rehabilitation, its practiced by the interdisciplinary team help the patient to stay at home, in familiar environment, where relaxation and comfort not founded in the environment of the hospital. Necessary equipment is brought home to conduct therapy, such as an infusion pump. From time to time, qualified medical personnel should visit the patients allow efficient communications with patients and their families, manage the therapy, checking bedsores, and explain proceedings in the case of unexpected health hazards. For patients who cannot be medically managed at home, staying in inpatient care units for control or alleviate the symptoms is not adequate or sufficient [171].
