Early in the course of dealing with cancer, treatments aim mostly at cure or at least a substantial prolongation of life. With these goals, it is certainly worth going through a lot of discomfort. However, when cancer recurs or spreads despite treatment, then the cancer is likely to cause death eventually. The benefits of further treatment aimed at modifying the cancer must always be weighed against the burdens those treatments will cause. Usually, a time comes when all of the available treatments to change the course of the cancer offer nothing worthwhile. Through all of this, treatments are always appropriate when they enhance comfort, improve your functioning, and support families. Even when there is "nothing more to do" about the cancer growth, there's "lots to do" to maintain comfort and give you the chance to do the things that are meaningful to you and your family.
Doctors use all kinds of terms for cancer - malignancy, carcinoma, lymphoma, tumor, and so on. Most people just see cancer as a word for a bad disease that can act like a parasite and destroy the body. About one-quarter of Americans will die from cancer. Compared to some other life-threatening diseases, cancer more often can be "managed." The time course is more well-understood, and most people are still able to take care of themselves and stay mentally alert until close to the end. For most people, with most cancers, pain is a real concern - but it can be controlled.
The term "cancer" refers to many diseases, each with its own distinctive characteristics. What is common to all is that some cell undergoes changes that allow it to grow in an abnormal fashion, multiplying uncontrollably. The continuing growth of these deviant cells leads to the development of a mass or growth called a tumor. Two unique characteristics of cancer cells create its life-threatening nature. First, cancer cells may spread to adjacent areas and invade normal tissues and organs, depriving them of nutrition and competing for space. Second, these cells may travel to a distant part of the body where they begin the development of another tumor, called a metastasis. The most common sites of metastatic spread are the bones, lungs, liver, brain, and central nervous system.
The most common signs and symptoms of advanced cancer are weakness, loss of appetite, loss of weight, pain, nausea, constipation, sleepiness or confusion, and shortness of breath. Pain is the most important symptom to plan for. Make sure that your doctor and your other caregivers are good at preventing and treating pain. Be sure also that your doctor and care team are experienced and comfortable in treating shortness of breath. Most serious symptoms in cancer are predictable, and prevention or rapid treatment works well. Thus, it is worthwhile to get your doctor to think with you about how to prevent or treat likely or very disruptive complications.
Some types of cancer - certain lymphomas, leukemias, and breast and prostate cancers - are characterized by a chronic nature. Long-term management using a combination of surgeries, medications, and radiation slows the progression of these diseases and alleviates symptoms. People live for many years with some of these illnesses.
When treatments won't really change the time course of the cancer, you still need comfort care, or what doctors call palliation, the relief of symptoms that interfere with your quality of life. In fact, you should aim to live well throughout the course of your illness, pursuing those personal goals that you can achieve while remaining comfortable at all times.
Treatment planning, how you and your doctor plan to manage and treat your disease, must be updated throughout the entire course of the disease. Cancer is often unpredictable. Furthermore, someone with advanced cancer who is receiving supportive and comfort care may need quite intrusive and technologically advanced treatment for specific emergencies, such as a broken bone, seizures, or tumors that compress the spinal cord. Occasionally, individuals who have not yet become debilitated can benefit from a short course of chemotherapy or radiation to reduce the size of a troublesome tumor. At all times, the benefits of any treatment must be weighed against its burdens. You don't want to be subjected to treatments that are worse than the disease!
Cancer has a special place in our culture, as a particularly evil menace. You may feel that way, or you may tell yourself, "I had to die sometime, and this is not the worst thing that could have happened." Sometimes having brochures from the American Cancer Society [ www.cancer.org ], the National Cancer Institute [ www.cancer.gov ], or other resources helps. You should know whether there are any implications of your having this cancer for your family - some cancers tend to run in families and some do not (and some are still unclear). You also should know whether anything you did contributed to the illness. You might want to consider how you will respond to insensitive people who blame you for your situation, something that often happens to smokers who develop lung cancer. Many people with cancer find it helpful to meet with others with their disease, perhaps in a support group, in order to hear how others deal with the challenges they confront.
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|Copyright © 1999, 2006 by Joanne Lynn. This extract from the Handbook for Mortals by Joanne Lynn, M.D. and Joan Harrold, M.D. is used with permission. To learn more about improving care at the end of life visit the main web site for Americans for Better Care of the Dying.|