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Esophageal Cancer
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Esophageal cancer

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DIGESTIVE SYSTEM
Cancer

The most common types of esophageal cancer are squamous cell carcinoma and adenocarcinoma, which develop in the cells that line the wall of the esophagus. These cancers may develop anywhere in the esophagus and may appear as a narrowing (stricture) of the esophagus, a lump, an abnormal flat area (plaque), or an abnormal connection (fistula) between the esophagus and the airways that supply the lungs.

Although doctors don't know all of the causes of esophageal cancer, certain factors greatly increase your risk. Among these are smoking, long-term alcohol abuse, and acid reflux, a condition that occurs when stomach acids back up into the lower part of your esophagus. Even mild chronic  heartburn- the kind of acid reflux you relieve with antacids - can make you more prone to esophageal cancer. A diet lacking in fruits, vegetables and certain nutrients also increases your risk.

In the past, the outlook for most people with esophageal cancer was poor. But survival rates have improved, in part because close monitoring of people with Barrett's esophagus - a serious, premalignant complication of acid reflux disease - can help detect cancer early, when it's more likely to respond to treatment. Even more encouraging is that diet and lifestyle changes may significantly reduce your chances of ever developing this type of cancer.

Signs and symptoms

It's unusual to have signs and symptoms of esophageal cancer in the early stages of the disease. When cancer is more advanced, you may experience:

  • Difficulty swallowing (dysphagia). Although this is the most common symptom of esophageal cancer, it usually doesn't appear until a tumor has grown large enough to narrow your esophagus to about half its normal width. At this point, meat and bread may be nearly impossible to eat, and you may unconsciously change your eating habits, chewing more slowly and carefully, for example, or switching to softer foods. But in time, you may even have trouble swallowing liquids.

  • Severe, unintentional weight loss. As eating becomes more difficult, you may not consume enough calories to maintain your weight. In addition, cancer in general can cause weight loss and muscle wasting because it changes the way your body metabolizes nutrients.

  • Pain in your throat, in your mid-chest or between your shoulder blades. Although not common, you sometimes might have pain when you swallow or discomfort or burning behind your breastbone.

  • Hoarseness, a chronic cough and sometimes coughing of blood. These symptoms usually don't appear until cancer is quite advanced.

Causes

Although your esophagus is essentially a hollow tube, its walls are composed of a number of highly-specialized layers, including an inner lining made up of thin, flat cells (squamous cells), a layer below the inner lining (submucosa) that contains mucus-secreting glands, and a thick band of muscle tissue.

When you eat or drink, a muscle in the upper part of your esophagus (upper esophageal sphincter) relaxes, allowing food and liquid to enter. Smooth muscles in the esophagus wall then move the food along in a series of rhythmic contractions — a process called peristalsis. It usually takes four to 10 seconds for food to flow through your esophagus.

Another ring of muscle, the lower esophageal sphincter, sits at the junction where your esophagus and stomach connect. It opens to allow food into your stomach and then clamps shut so that corrosive stomach acids and digestive enzymes don't back up into the esophagus.

Cancer can occur almost anywhere along the length of the esophagus and is classified according to the types of cells in which it originates:

  • Squamous cell or epidermoid carcinoma. The most common esophageal cancer in black Americans, squamous cell carcinoma develops in the flat squamous cells that line the esophagus.

  • Adenocarcinoma. This arises in the glandular tissue in the lower part of the esophagus nearest the stomach. Adenocarcinoma is more common in white than in black poeple.

  • Others. Although squamous cell and adenocarcinoma are the primary types of esophageal cancer, other, rare forms of the disease sometimes occur. These include sarcoma, lymphoma, small cell carcinoma and spindle cell carcinoma. In addition, cancer that starts in the breast or lung can spread (metastasize) through the bloodstream or lymph system to the esophagus.

Contributing factors
Healthy cells grow and divide in an orderly way. This process is controlled by DNA — the genetic material that contains the instructions for every chemical process in your body. When DNA is damaged, changes occur in these instructions. One result is that cells may begin to grow out of control and eventually form a tumor — a mass of malignant cells.

Although researchers don't know all the causes of esophageal cancer, they have identified several factors that can damage DNA in your esophagus. These factors include:

  • Heavy alcohol consumption. Esophageal squamous cell carcinomas result from chronic alcohol abuse. Long-term heavy drinking irritates the lining of the esophagus, leading to inflammation that eventually may cause malignant changes in the cells.

  • Tobacco use. Using tobacco in any form, including cigarettes, cigars, pipes and chewing tobacco, increases the likelihood of developing esophageal squamous cell carcinoma. The risk increases with long-term use and rises dramatically for people who both smoke and drink.

  • Chronic acid reflux. Sometimes the lower esophageal sphincter relaxes abnormally or weakens, allowing caustic stomach acids to back up into your esophagus (esophageal reflux). The result is heartburn — a burning chest discomfort that in severe cases may mimic the symptoms of a heart attack. Occasional heartburn usually isn't serious, but chronic acid reflux can lead to Barrett's esophagus, a condition in which cells similar to the stomach's glandular cells develop in the lower esophagus. These new cells are resistant to stomach acid, but they also have a high potential for malignancy.

  • Chemical irritation. Each year, nearly 1 million children under age 5 accidentally drink toxic household substances. Some of these chemicals, especially drain cleaners that contain lye, burn the lining of the esophagus and may contribute to esophageal cancer later in life.

  • Diet. Eating a diet low in fruits and vegetables appears to contribute to esophageal cancer. Especially implicated are diets lacking in vitamins A, C, B1 (riboflavin), the mineral selenium, and beta-carotene — a substance found especially in orange and yellow fruits and vegetables that is converted into vitamin A in your body.

  • Obesity. Weighing 20 to 30 pounds more than your ideal weight has been linked to an increased risk of adenocarcinoma.

Sometimes esophageal cancer is associated with certain rare medical conditions, including:

  • Achalasia. In this disorder, food collects at the bottom of the esophagus, both because the esophagus lacks normal peristalsis to move food along and because the lower esophageal sphincter doesn't relax normally. For reasons that aren't clear, having achalasia seems to increase your risk of esophageal cancer.

  • Esophageal webs. These thin protrusions of tissue can appear anywhere in the esophagus. Some webs cause no symptoms, but others can make swallowing difficult. When other problems — including anemia and abnormalities of the tongue, fingernails and spleen — occur in conjunction with esophageal webs, the condition is called Plummer-Vinson or Paterson-Kelly syndrome. People with this syndrome are at risk of developing esophageal cancer.

  • Tylosis. This rare, inherited disorder causes excess skin to form on the soles and palms. Close to half the people with tylosis eventually develop esophageal cancer. A genetic defect appears to be responsible for both tylosis and the associated cancer.

Risk factors

Heavy drinking and smoking are the two greatest risk factors for esophageal squamous cell carcinoma. The risk increases substantially if you drink as well as smoke. If you drink heavily every day for several years, your risk of esophageal cancer is 18 times greater than it is for someone who drinks in moderation or not at all. When you also smoke, your risk nearly doubles.

Other risk factors for esophageal cancer include:

  • Age. Your risk of developing esophageal cancer increases as you grow older. Most people with the disease are between 45 and 70. The risk is much less if you're under 40.

  • Sex. Men are three times as likely to develop esophageal cancer as women are.

  • Race. Squamous esophageal cancer affects three times as many black Americans as whites, whereas whites have much higher rates of esophageal adenocarcinoma than do blacks. Although the reason for this disparity isn't known, genetic factors may play a role.

  • Diet. If your diet is low in fruits and vegetables, or you're very overweight, you're at increased risk of esophageal cancer. To help protect your health, the American Cancer Society recommends eating five or more servings of vegetables and fruits each day, using whole grains such as brown rice and whole wheat instead of refined or processed grains, and limiting red meat.

  • Chronic heartburn or Barrett's esophagus. Both conditions, which occur when stomach acid backs up into your esophagus, increase your risk of esophageal cancer.

When to seek medical advice

See your doctor if you have difficulty swallowing, a chronic cough or unintended weight loss. Having these signs and symptoms doesn't mean you have esophageal cancer. A number of other conditions can cause similar problems, and your doctor can perform tests to help determine the cause.

Also seek treatment if you experience chronic heartburn, which can cause inflammation in your esophagus and increase your risk of esophageal cancer. In many cases, you can control mild or moderate heartburn by changing your diet and using over-the-counter antacids. When these measures aren't enough, your doctor may recommend stronger medications.

Signs and symptoms of gastroesophageal reflux include:

  • A sour taste and the sense of food re-entering your mouth (regurgitation)

  • Burning chest pain, especially after meals or at night when lying down

  • Difficulty swallowing, often due to a spasm or stricture in your esophagus

  • Coughing, wheezing, asthma, hoarseness or sore throat, often resulting from acid reflux in your throat or windpipe

Screening and diagnosis

To help find the cause of your symptoms, your doctor will take a complete medical history and perform a physical exam. You're also likely to have a chest X-ray and other diagnostic tests, such as:

  • A barium swallow (esophagram). A diagnostic test often given to people who have difficulty swallowing, a barium swallow uses a series of X-rays to examine the esophagus. Before the test, you'll drink a thick liquid (barium) that temporarily coats the lining of your esophagus so that the lining shows up clearly on the X-rays. You may also have air blown into your esophagus, to help push the barium against the esophagus walls. Although a barium swallow can help diagnose cancer, it may not show whether a tumor has spread beyond the esophagus. After the test you can eat normally and resume your daily activities, although you'll need to drink extra water to help flush the barium from your system and prevent constipation. A barium swallow briefly exposes you to ionizing radiation. The danger from this exposure is small and doesn't appear to increase even if you have a number of X-rays. Even so, care is taken to produce the best images with the lowest amount of radiation and the fewest possible X-rays.

  • Esophagoscopy (upper endoscopy). During this procedure, your doctor examines the inside of your esophagus using an endoscope — a thin, lighted tube with a tiny camera on the end that sends images to a TV monitor. Your throat will likely be sprayed with a topical anesthetic before you're asked to swallow the tube, and you may also receive medication through your veins (intravenously) to keep you relaxed and comfortable. The endoscope allows your doctor to clearly see any masses in the wall of your esophagus as well as to take a tissue sample (biopsy) if abnormal cells are found. The samples are then sent to a laboratory for analysis. Risks of the procedure include a reaction to the medication and bleeding at a biopsy site. If your doctor needs to make a wider opening (dilate) your esophagus because of a stricture or narrowing, there's also a small risk of creating a hole in your esophagus (esophageal perforation).

Screening tests
Screening tests check for a disease in its early stages, before you develop symptoms. If you're at high risk of esophageal cancer, especially if you have Barrett's esophagus or tylosis, you're likely to have regular endoscopic examinations and biopsies. Many doctors recommend having these tests every two to three years if you don't have cell abnormalities (dysplasia). When cell abnormalities are present, you'll usually need tests more often.

Staging tests
If cancer is diagnosed, you're likely to have more tests to determine whether and where the cancer has spread (metastasized), a process known as staging. This step is especially important because it helps your doctor determine the best possible treatment. Esophageal cancers are staged using the numbers 0 through IV. In general, the higher the number the more advanced the cancer.

  • Stage 0 (carcinoma in situ). These cancers, also called noninvasive or in situ (in one place) cancers or high-grade dysplasia, don't have the ability to spread to other parts of your body. Still, it's important to have them followed closely or removed because they eventually may become invasive.

  • Stage I. This cancer occurs only in the top layer of cells lining your esophagus.

  • Stage II. At this stage, the cancer has invaded deeper layers of your esophagus lining and may have also spread to nearby lymph nodes.

  •  Stage III. The cancer has spread even more deeply into the wall of your esophagus and to nearby tissues or lymph nodes.

  • Stage IV. At this stage, the cancer has spread to other parts of your body.

To help stage esophageal cancer, you may have one or more of these tests:

  • Bronchoscopy. In this procedure, which is similar to esophagoscopy, your doctor uses an endoscope to examine your windpipe (trachea) and the air passages leading to your lungs (bronchi) to determine whether cancer has spread to these areas.

  • Computerized tomography (CT) scan. This X-ray technique produces more detailed images of your internal organs than do conventional X-ray studies. That's because a computer translates information from X-rays into images of thin sections (slices) of your body at different levels. CT scans can confirm the location of a tumor within the esophagus and whether cancer has spread to nearby lymph nodes or other organs. A CT scan exposes you to more ionizing radiation than plain X-rays do and usually isn't recommended if you're pregnant.

  • Endoscopic ultrasound. This procedure may prove to be more accurate than either CT scans or upper endoscopy in determining how far an esophageal cancer has spread into nearby tissues. During the test, a tiny ultrasound probe is passed through an endoscope into your esophagus. The probe produces very sensitive sound waves that penetrate deep into tissues. A computer then translates the sound waves into close-up images of your esophagus and nearby tissues. Your doctor can also take biopsies of lymph nodes and other tissues during the procedure. Endoscopic ultrasound uses sound waves rather than X-rays to create images, and the risks of the procedure, such as bleeding or perforation of the esophagus, are slight.

  • Positron emission tomography (PET) scan. During this test, your doctor injects a small amount of a radioactive tracer — typically a form of glucose — into your body. All tissues in your body absorb some of this tracer, but tumors absorb greater amounts and appear brighter on the scan than healthy tissue does. A PET scan exposes you to a small amount of radiation, but because the radioactivity is short-lived, your overall exposure is low.

Complications

As esophageal cancer advances, the tumor may block more and more of your esophagus, making swallowing increasingly difficult. Eventually, some people aren't able to swallow their own saliva. To help make swallowing easier or reduce the size of the tumor, your doctor may stretch your esophagus with a balloon-like device, vaporize the tumor with a laser, or insert a stainless steel or plastic tube (stent) to hold your esophagus open.

Other complications of esophageal cancer include:

  • Tracheoesophageal fistula. This occurs when a tumor creates a hole between your esophagus and windpipe, leading to coughing and gagging when you swallow. A tracheoesophageal fistula requires surgery or the use of a stent to prevent food or liquid from your esophagus entering your windpipe and lungs.

  • Severe, unintended weight loss. About half the people with esophageal cancer experience severe weight loss and weakness, usually because of cancer-caused changes in metabolism or because swallowing is painful and difficult.

  • Metastasis. This is the most serious complication of esophageal cancer. Because esophageal tumors are rarely discovered in the early stages, they often have spread to nearby lymph nodes or to other parts of your body, such as the lungs or liver, before they're diagnosed.

Treatment

Treatment for esophageal cancer depends on the type, location and stage of cancer as well as on your age, overall health and personal preferences. Decisions about therapy can be particularly complicated because various combinations of surgery, chemotherapy and radiation may be more effective than any single treatment. When cancer is advanced, choosing a treatment plan is a major decision, and it's important to take time to evaluate your choices.

You may also want to consider seeking a second opinion. This can provide additional information to help you feel more certain about the option you're considering.

The goal of treatment is to eliminate the cancer completely. When that isn't possible, the focus may be on preventing the tumor from growing or causing more harm. In some cases, an approach called palliative care may be best. Palliative care refers to treatment aimed not at removing or slowing the disease, but at helping relieve symptoms and making you as comfortable as possible.

Surgical options
Surgery is the most common treatment for esophageal cancer, either as a therapy for the cancer itself or as a way to relieve symptoms, especially difficult swallowing. It's also recommended if you consistently have very abnormal cells (high-grade dysplasia) occurring with Barrett's esophagus.

Depending on the nature of the cancer, the operation may be performed in one of two ways:

  • Esophagectomy. Doctors generally recommend this approach for early-stage esophageal cancer that doesn't involve your stomach. During the procedure, your surgeon removes the portion of your esophagus that contains the tumor along with nearby lymph nodes. The remaining esophagus is reconnected to your stomach so you can still swallow. In some cases the stomach is pulled up to the esophagus. In others, part of your large intestine is used to replace the missing section of your esophagus.

  • Esophagogastrectomy. In this procedure, which is used for more advanced cancer, your surgeon removes part of your esophagus, nearby lymph nodes and the upper part of your stomach. The remainder of your stomach is then pulled up and reattached to your esophagus. If necessary, part of your colon is used to help join the two.

Surgery for esophageal cancer is complex and carries risks that include infection, bleeding and leakage from the area where the remaining esophagus is reattached. Hospitals where surgeons perform a large number of esophagectomies have significantly lower mortality rates than do hospitals where few esophagectomies are performed. If you're considering this surgery, look for a hospital or medical center whose surgeons are highly experienced in the procedure.

Chemotherapy
Using drugs to kill cancer cells is another option for treating esophageal cancer. Chemotherapy medications, which can be injected into a vein or taken by mouth, travel throughout your body, attacking cancer cells that have spread beyond your esophagus. You usually receive a combination of anticancer drugs given in cycles, with periods of recovery alternating with periods of treatment.

Chemotherapy can help in several ways — before surgery to shrink the tumor, in combination with radiation when surgery isn't an option, or to relieve symptoms in advanced cases of esophageal cancer.

Unfortunately, anticancer drugs affect normal cells as well as malignant ones, especially fast-growing cells in your digestive tract and bone marrow. For that reason, side effects — including nausea and vomiting, mouth sores, an increased chance of infection due to a shortage of white blood cells, and fatigue — are common. Not everyone experiences side effects however, and there are now better ways to control them if you do. Be sure to discuss any questions you may have about side effects with your treatment team.

Radiation therapy
Radiation is usually most effective against esophageal cancer when used in combination with chemotherapy, either before surgery or as the primary treatment. It's also used to relieve pain and improve swallowing. Most often, the radiation comes from a machine outside your body (external beam radiation), but sometimes thin plastic tubes containing radioactive material are implanted near the cancer cells in your esophagus (brachytherapy). Your doctor may insert a plastic or metal stent to keep your esophagus open during treatment.

You commonly receive radiation therapy five days a week for five to seven weeks. The most common side effects are fatigue — which generally becomes more noticeable later in the course of treatment — skin rash or redness in the area being treated, loss of appetite, and mouth sores or increased problems with swallowing.

These side effects generally aren't permanent, and most can be treated or controlled. Long-term side effects are rare, but they can be serious when they do occur and include inflammation or scarring in the lungs, esophagus, heart or spinal cord.

Photodynamic therapy
This therapy is generally used to relieve pain and obstruction in the esophagus, but it's also being studied as a treatment for early-stage esophageal cancer. During the procedure, you receive an injection of a light-sensitive drug that remains in cancer cells longer than it does in healthy ones. A laser light is then directed at your esophagus through an endoscope. This stimulates the production of an active form of oxygen that destroys the cancer cells while sparing healthy tissue.

Photodynamic therapy isn't without side effects. It makes your skin and eyes sensitive to light for at least six weeks after treatment, so you'll need to wear protective clothing and sunglasses every time you go outdoors. It can also make swallowing even more difficult for a short period of time.

Areas of research
Scientists are continually seeking more effective and less harmful treatments for esophageal cancer. Some areas of research include:

  • Gene therapy. Researchers have identified many of the genetic changes that cause healthy esophageal cells to become malignant. Understanding these changes may eventually lead to gene therapies that help repair abnormal DNA.

  • Chemotherapy. Scientists are studying a range of chemotherapy options, including new anticancer drugs such as tyrosine-kinase inhibitors. Protein tyrosine kinases are substances that help regulate signals between cells, especially those having to do with the cell growth and mortality. Because abnormal signals from protein tyrosine kinases have been linked to a number of different cancers, some researchers have focused on finding ways to selectively inhibit these signals. Also under investigation are new combinations of existing drugs and different combinations of radiation and chemotherapy.

  • Immunotherapy. This therapy stimulates your immune system to fight cancer. One approach uses monoclonal antibodies, which are produced by fusing antibody-forming cells and tumor cells, to treat esophageal adenocarcinomas.

Prevention

Although it's not possible to prevent all cases of esophageal cancer, the following lifestyle changes can greatly reduce your risk:

  • Quit smoking. This may be the single most important thing you can do to prevent esophageal cancer and improve your overall health. Cigarette smoke contains carcinogens that can damage the DNA that regulates cell growth.

  • Limit alcohol consumption. Nearly three-fourths of esophageal squamous cell carcinomas and many adenocarcinomas result from heavy alcohol consumption over a period of years. Drinking in moderation or abstaining from alcohol can greatly reduce your risk of this type of esophageal cancer.

  • Get help for heartburn. Don't ignore severe or frequent heartburn. Your doctor can recommend medications and lifestyle changes that can help prevent gastric reflux. Sometimes drugs that inhibit acid formation may provide the relief you need. You may also be helped by avoiding acidic, spicy or fatty foods, by waiting at least two to three hours after eating before lying down or exercising, and by elevating the head of your bed.

  • Eat a healthy diet. Eating more fruits and vegetables, especially those rich in beta-carotene, and vitamins A, C and B-1, can help protect against esophageal cancer. Look for deep green and dark yellow or orange fruits and vegetables, such as Swiss chard, bok choy, spinach, cantaloupe, mango, acorn or butternut squash, and sweet potatoes. Also try to eat vegetables from the cabbage family, including broccoli, brussels sprouts and cauliflower. Lycopene, a nutrient found in tomatoes and other red fruits and vegetables, such as strawberries and red bell peppers, may be a particularly powerful anticancer chemical. Because diets low in selenium have been linked to esophageal cancer, try to include foods rich in this mineral, such as milk, broccoli, cabbage, fish and whole grains. Healthy adults should ingest at least 55 micrograms (mcg) of selenium every day. A slice of whole-wheat bread contains 10 mcgs.

  • Maintain a healthy weight. Being significantly overweight (obese) increases your risk of esophageal cancer as well as your risk of other serious health problems, such as diabetes, cardiovascular disease and stroke. Slow and steady weight loss of 1 or 2 pounds a week is considered the safest way to lose weight and keep it off. In many cases, you can lose weight by committing to eating a healthier diet, exercising and changing unhealthy behaviors. Other treatments for obesity include prescription medications and surgery.

Self-care

Poor appetite, difficulty swallowing, weight loss and weakness are often problems for people with esophageal cancer. These symptoms may be compounded by cancer treatments and by the need for a liquid diet or intravenous feeding during the course of your treatment as well as by the emotional toll of living with the disease.

When you're able to eat more normally, your doctor may recommend talking to a registered dietitian. He or she can help you find ways to get the nourishment you need. These suggestions also may help:

  • Try eating several small meals throughout the day instead of two or three larger ones. If you are nauseous or have trouble swallowing, choose foods that are soothing and easy-to-swallow, such as soups, yogurt or milkshakes.

  • Talk to your doctor about vitamin and mineral supplements. If you haven't been eating as much as you normally would or if your diet is restricted, you're likely deficient in a variety of nutrients.

  • Have nourishing snacks within easy reach. That way, you're more likely to eat. Fresh fruit and yogurt are good choices.

Coping skills

Learning you have any life-threatening illness can be devastating. But coping with a diagnosis of esophageal cancer can be especially difficult. The more advanced the disease when it's discovered, the less likely the chance of real recovery. As a result, you may feel especially overwhelmed just when you need to make crucial decisions. Although there are no easy answers for people dealing with esophageal cancer, some of the following suggestions may help:

Learn all you can about your illness. Learn everything you can about esophageal cancer — how the disease progresses, your prognosis and your treatment options, including both experimental and standard treatments and their side effects. Be sure you understand whether a particular approach is used to treat cancer or provide palliative care. Don't be afraid to seek a second opinion and to explore treatments available through clinical trials. You'll have many decisions to make in the weeks and months ahead. The more you know, the more active a role you can take in the decision-making process.

Maintain a strong support system. Strong relationships are crucial in dealing with life-threatening illnesses. Although family and friends can be your best allies, in some cases they may have trouble dealing with your illness. Or you may not have a large social network. If so, the concern and understanding of a counselor, medical social worker, pastoral or religious counselor, or even a formal support group can be helpful. Although support groups aren't for everyone, they can sometimes be a good resource for practical information about your disease. You may also find strength and encouragement in being with people who are facing the same challenges you are.

If you're interested in learning more about support groups, talk to a doctor, nurse, social worker or psychologist. They may be able to put you in touch with a group in your area. Or check your local phone book, library or cancer organization. The National Cancer Institute also can provide a list of support groups. After deciding to participate in a group, try it out a few times. If it doesn't seem useful or comfortable, you don't have to continue.

Come to terms with your illness. Coming to terms with your illness may be the hardest thing you've ever done. For some people, having a strong faith or a sense of something greater than themselves makes this process easier. Others seek counseling from someone who understands life-threatening illnesses, such as a medical social worker, psychologist or chaplain. Many people also take steps to ensure that their end-of-life wishes are known and respected.

Fears shared by many people with a life-threatening illness include being subjected to treatments they don't want, becoming a burden to their loved ones, and spending their last weeks or months in a hospital away from familiar surroundings. The welcome news is that many more choices now exist for people with a terminal illness.

Hospice care, for example, provides a special course of treatment to terminally ill people. This allows family and friends — with the aid of nurses, social workers and trained volunteers — to care for and comfort a loved one at home or in hospice residences. It also provides emotional, social and spiritual support for people who are ill and those closest to them. Although most people under hospice care remain in their own homes, the program is also available in other locations — including nursing homes and assisted living centers. For those who stay in a hospital, palliative care specialists can provide comfort, compassionate care and dignity.

Although it can be extremely difficult, discuss end-of-life issues with your family and medical team. Part of this discussion will likely involve advance directives — a general term for oral and written instructions you give concerning your medical care should you become unable to speak for yourself.

Complementary and alternative medicine

More and more people are interested in nontraditional approaches to healing, especially when standard treatments produce intolerable side effects or aren't able to provide a cure. In general, alternative medicine refers to therapies that may be used instead of conventional treatments. Complementary or integrative medicine, on the other hand, usually means therapies used in conjunction with traditional treatments.

Rather than simply addressing a problem with the body, complementary and alternative treatments often focus on the entire person — body, mind and spirit. As a result, they can be especially effective at reducing stress, alleviating the side effects of conventional treatments such as chemotherapy and improving quality of life.

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