Secretory carcinoma of the breast is a rare and indolent tumour originally described in children but occurring equally in the adult population. The principal management problems following primary surgical treatment are local recurrence and axillary lymph node metastases. Distant metastases are extremely rare. We present the case of a 27-year-old woman with pulmonary metastases from a secretory breast cancer treated by mastectomy and axillary lymph node dissection 12 years previously. There was no response to chemotherapy; however, the patient remained alive and active two years from presentation with metastatic disease and one year from cessation of all cytotoxic chemotherapy. She eventually died of respiratory failure two and a half years after presentation. To our knowledge, this is only the fourth reported case of distant metastases from secretory breast cancer and the second reported case in which current active chemotherapy has been used. We review the literature and discuss the apparent chemoresistance of this tumour including the lack of membrane staining for Her2/neu. In the absence of any proven effective chemotherapy we believe that symptom control becomes the focus of management and offers patients with metastatic secretory breast cancer the greatest chance of a functional and good quality existence.

Advance care planning can assist patients to achieve a sense of control and 'peace of mind' and facilitates important family discussion. However, the timing and style of its introduction needs to be approached sensitively. Tools and strategies for increasing the efficacy of advance care planning for motor neuron disease should be evaluated and implemented.

RUNNING TITLE: PROOF OF LOVE Background: Motor neurone disease (MND) remains universally fatal despite the introduction of diseasemodifying therapy in the form of the glutamate inhibitor, riluzole. Caring for people with MND presents enormous challenges, many of which are particular to the disease complex. An understanding of the carer burden is required in order to inform the delivery of palliative care to MND patients and their carers. Aim: To explore the experiences and perceptions of carers and former carers of people with MND with emphasis on the later stages of the disease. Participants and Methods: Focus groups were conducted with two groups of former carers and one group of current carers recruited through the Motor Neurone Disease Association of NSW. Recruitment continued until no new themes emerged. The discussions were taped, transcribed verbatim and content analysed. Results: There was a clear thematic trajectory from diagnosis through to death and bereavement with ramifications evident for the delivery of palliative care. Unmet emotional needs and the unremitting and all-encompassing nature of care were emphasised, as was the importance of love in sustaining the carer. Conclusions: The experience of caring for a person with MND has a lasting psychological impact which may outweigh the physical and financial costs of care. This relatively unexplored area of enquiry lacks adequate models on which to base quantitative investigation. This qualitative study provides a starting point for future research.

An individualised disease-specific letter expressing patient's wishes for their future care was offered to people with Amyotrophic Lateral Sclerosis (ALS) from 2001 to 2008. All patients attended a multidisciplinary ALS service where they were seen by a palliative physician. Each letter was developed in a process of drafting and revision over several consultations. The letter conformed with government and Catholic health guidelines on advance care planning. It rapidly developed into a tool to facilitate discussion and became known as the Letter on Future Care (LFC). Although individualised care planning is now the standard, an LFC is not known to be in use elsewhere. A series of studies was undertaken to evaluate the LFC, focussing initially on the carer's experience. Past carers were identified: 10 past carers where an LFC was written and 9 past carers where there was no LFC. Semi-structured interviews were held with each carer. Each was shown a sample LFC for consideration or as a memory prompt. Interviews were audiotaped, transcribed and analysed. Themes were extracted and characteristic quotes identified. A questionnaire was developed to elicit a critique of the LFC from a purposive sample of ALS health professionals including neurologists, palliative physicians and nurse specialists. Data were analysed. An expert panel was convened to develop Guidelines. In this presentation, we will examine the views of the carers, and the critique given by health professionals. We will examine the structure of sample LFCs. We will propose the Guidelines for comment and discuss prospective testing of this approach.